Combination of bcl-2 inhibitor and mek inhibitor for the treatment of cancer

ABSTRACT

The present invention is directed to a combination therapy involving a selective Bcl-2 inhibitor and a MEK inhibitor for the treatment of a patient in need of such a therapy. The patient in need of the combination therapy is suffering from cancer, such as acute myeloid leukemia.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a divisional application of U.S. application Ser.No. 15/767,914, filed Apr. 12, 2018, the contents of which are herebyincorporated by reference as if set forth in its entirety. U.S.application Ser. No. 15/767,914 is the 35 U.S.C. § 371 national stage ofInternational Application No. PCT/US2016/060271, filed Nov. 3, 2016, thecontents of which are hereby incorporated by reference as if set forthin its entirety. International Application No. PCT/US2016/060271 claimspriority to U.S. provisional application Ser. No. 62/250,231, filed Nov.3, 2015, the contents of which are hereby incorporated by reference asif set forth in its entirety. International Application No.PCT/US2016/060271 claims priority to U.S. provisional application Ser.No. 62/263,082, filed Dec. 4, 2015, the contents of which are herebyincorporated by reference as if set forth in its entirety.

FIELD OF THE INVENTION

The present invention is directed to a combination therapy involving aselective Bcl-2 inhibitor and a MEK inhibitor for the treatment of apatient in need of such a therapy, and more particularly is directed tothe combination of venetoclax (ABT-199/GDC-0199) and cobimetinib(GDC-0973).

BACKGROUND OF THE INVENTION

Protein kinases are enzymes that catalyze the phosphorylation ofproteins, and in particular the hydroxy groups on tyrosine, serine, andthreonine residues of proteins. The consequences of this seeminglysimple activity are significant. Cell differentiation and proliferation(i.e., virtually all aspects of cell life, in one-way or another) dependon protein kinase activity. Furthermore, abnormal protein kinaseactivity has been related to a host of disorders, ranging fromrelatively non-life threatening diseases, such as psoriasis, toextremely virulent diseases, such as glioblastoma (brain cancer).

Protein kinases can be categorized as receptor type or non-receptortype. Receptor-type tyrosine kinases have an extracellular, atransmembrane, and an intracellular portion, while non-receptor typetyrosine kinases are wholly intracellular. They are comprised of a largenumber of transmembrane receptors with diverse biological activity. Infact, about 20 different subfamilies of receptor-type tyrosine kinaseshave been identified. One tyrosine kinase subfamily, designated the HERsubfamily, is comprised of EGFR (HER1), HER2, HER3, and HER4. Ligands ofthis subfamily of receptors identified so far include epithelial growthfactor, TGF-alpha, amphiregulin, HB-EGF, betacellulin, and heregulin.Another subfamily of these receptor-type tyrosine kinases is the insulinsubfamily, which includes INS-R, IGF-IR, and IR-R. The PDGF subfamilyincludes the PDGF-alpha and beta receptors, CSFIR, c-kit, and FLK-II. Inaddition, there is the FLK family, which is comprised of the kinaseinsert domain receptor (KDR), fetal liver kinase-1 (FLK-1), fetal liverkinase-4 (FLK-4), and the fms-like tyrosine kinase-1 (flt-1). The PDGFand FLK families are usually considered together due to the similaritiesof the two groups. (For a detailed discussion of the receptor-typetyrosine kinases, see Plowman et al., DN&P 7(6): 334-339, 1994, which ishereby incorporated by reference.)

The non-receptor type of tyrosine kinases is also comprised of numeroussubfamilies, including Src, Frk, Btk, Csk, Abl, Zap70, Fes/Fps, Fak.Jak, Ack, and LIMK. Each of these subfamilies is further sub-dividedinto varying receptors. For example, the Src subfamily is one of thelargest and includes Src, Yes, Fyn, Lyn, Lck, Blk, Hck, Fgr, and Yrk.The Src subfamily of enzymes has been linked to oncogenesis. (For a moredetailed discussion of the non-receptor type of tyrosine kinases, seeBolen, Oncogene, 8:2025-2031 (1993), which is hereby incorporated byreference.)

Since protein kinases and their ligands play critical roles in variouscellular activities, deregulation of protein kinase enzymatic activitycan lead to altered cellular properties, such as uncontrolled cellgrowth associated with cancer. In addition to oncological indications,altered kinase signaling is implicated in numerous other pathologicaldiseases. These include, but are not limited to: immunologicaldisorders, cardiovascular diseases, inflammatory diseases, anddegenerative diseases. Therefore, both receptor and non-receptor proteinkinases are attractive targets for small molecule drug discovery.

One particularly attractive goal for therapeutic use of kinasemodulation relates to oncological indications. For example, modulationof protein kinase activity for the treatment of cancer has beendemonstrated successfully with the FDA approval of Gleevec® (imatinibmesylate, produced by Novartis Pharmaceutical Corporation of EastHanover, N.J.) for the treatment of Chronic Myeloid Leukemia (CML) andgastrointestinal stroma cancers. Gleevec is a selective Abl kinaseinhibitor.

Modulation (particularly inhibition) of cell proliferation andangiogenesis, two key cellular processes needed for tumor growth andsurvival (Matter A. Drug Disc Technol 20016, 1005-1024), is anattractive goal for the development of small-molecule drugs.Anti-angiogenic therapy represents a potentially important approach forthe treatment of solid tumors and other diseases associated withdysregulated vascularization, including ischemic coronary arterydisease, diabetic retinopathy, psoriasis and rheumatoid arthritis. Cellanti-proliferative agents are desirable to slow or stop the growth oftumors.

One particularly attractive target for small-molecule modulation, withrespect to antiangiogenic and anti-proliferative activity is MEK.Inhibition of MEK1 (MAPK/ERK Kinase) is a promising strategy to controlthe growth of tumors that are dependent on aberrant ERK/MAPK pathwaysignaling (Solit et al., 2006; Wellbrock et al., 2004). The MEK-ERKsignal transduction cascade is a conserved pathway, which regulates cellgrowth, proliferation, differentiation, and apoptosis in response togrowth factors, cytokines, and hormones. This pathway operatesdownstream of Ras which is often upregulated or mutated in human tumors.It has been demonstrated that MEK is a critical effector of Rasfunction. The ERK/MAPK pathway is upregulated in 30% of all tumors andoncogenic activating mutations in K-Ras and B-Raf have been identifiedin 22% and 18% of all cancers respectively (Allen et al., 2003; BamfordS, 2004. Davies et al., 2002; Malumbres and Barbacid, 2003). It has beenreported that a large portion of human cancers, including 66% (B-Raf) ofmalignant melanomas, 60% (K-Ras) and 4% (B-Raf) of pancreatic cancers,50% of colorectal cancers (colon, in particular, K-Ras: 30%, B-Raf 15%),20% (K-Ras) of lung cancers, 27% (B-Raf) papillary and anaplasticthyroid cancer, and 10-20% (B-Raf) of endometriod ovarian cancers,harbor activating Ras and Raf mutations. It has been shown thatinhibition of the ERK pathway, and in particular inhibition of MEKkinase activity, results in anti-metastatic and anti-angiogenic effectslargely due to a reduction of cell-cell contact and motility as well asdownregulation of vascular endothelial growth factor (VEGF) expression.Furthermore, expression of dominant negative MEK, or ERK reduced thetransforming ability of mutant Ras as seen in cell culture and inprimary and metastatic growth of human tumor xenografts in vivo.Therefore, the MEK-ERK signal transduction pathway is an appropriatepathway to target for therapeutic intervention.

The Bcl-2 family of proteins regulates programmed cell death triggeredby developmental cues and in response to multiple Stress signals (Cory.S., and Adams, J. M., Nature Reviews Cancer 2 (2002) 647-656: Adams,Genes und Development 17 (2003) 2481-2495; Danial, N. N., and Korsmeyer.S. J., Cell 116 (2004) 205-219). Whereas cell survival is promoted byBcl-2 itself and several close relatives (Bcl-xL, Bcl-W. Mcl-1, and Al),which bear three or four conserved Bcl-2 homology (BH) regions,apoptosis is driven by two other subfamilies. The initial signal forcell death is conveyed by the diverse group of BH3-only proteins,including Bad, Bid, Bim, Puma and Noxa, which have in common only thesmall BH3 interaction domain (Huang and Strasser, Cell 103 (2000)839-842). However, Bax or Bak, multi-domain proteins containing BH1-BH3,are required for commitment to cell death (Cheng, et al., Molecular Cell8 (2001) 705-711; Wei, M. C., et al., Science 292 (2001) 727-730; Zong,W. X., et al., Genes and Development 15 148 (2001) 1-1486). Whenactivated, they can permeabilize the outer membrane of mitochondria andrelease pro-apoptogenic factors (e.g., cytochrome C) needed to activatethe caspases that dismantle the cell (Wang, K., Genes and Development 15(2001) 2922-2933; (Adams, 2003 supra); Green, D. R., and Kroemer, G.,Science 305 (2004) 626-629).

Interactions between members of these three factions of the Bcl-2 familymay dictate whether a cell lives or dies. When BH3-only proteins havebeen activated, for example, in response to DNA damage, they can bindvia their BH3 domain to a groove on their pro-survival relatives(Sattler, et al., Science 275 (1997) 983-986). How the BH3-only andBcl-2-like proteins control the activation of Bax and Bak, however,remains poorly understood (Adams, 2003 supra). Most attention hasfocused on Bax. This soluble monomeric protein (Hsu, Y. T., et al.,Journal of Biological Chemistry 272 (1997) 13289-13834; Wolter, K. G.,et al., Journal of Cell Biology 139 (1997) 1281-92) normally has itsmembrane targeting domain inserted into its groove, probably accountingfor its cytosolic localization (Nechushtan. A., et al., EMBO Journal 18(1999) 2330-2341; Suzuki, et al., Cell 103 (2000) 645-654; Schinzel, A.,et al., J Cell Biol 164 (2004) 1021-1032). Several unrelatedpeptides/proteins have been proposed to modulate Bax activity (see,e.g., Lucken-Ardjomande, S., and Martinou, J. C., J Cell Sci 118 (2005)473-483), but their physiological relevance remains to be established.Alternatively, Bax may be activated via direct engagement by certainBH3-only proteins (Lucken-Ardjomande, S., and Martinou, J. C, 2005supra), the best documented being a truncated form of Bid, tBid (Wei, M.C., et al., Genes und Development 14 (2000) 2060-2071; Kuwana, T., etal., Cell 111 (2002) 331-342; Roucou, X., et al., Biochemical Journal368 (2002) 915-921; Catron, P. F., et al., Mol Cell 16 (2004) 807-818).As discussed elsewhere (Adams 2003 supra), the oldest model, in whichBcl-2 directly engages Bax (Oltvai, Z. N., et al., Cell 74 (1993)609-619), has become potentially problematic because Bcl-2 is membranebound while Bax is cytosolic, and their interaction seems highlydependent on the detergents used for cell lysis (Hsu, Y. T., and Youle,1997 supra). Nevertheless, it has been established that the BH3 regionof Bax can mediate association with Bcl-2 (Zha, H. and Reed, J., Journalof Biological Chemistry 272 (1997) 31482-88; Wang, K., et al., Molecularand Cellular Biology 18 (1998) 6083-6089), and that Bcl-2 may preventthe oligomerization of Bax, even though no heterodimers can be detected(Mikhailov. V., et al., Journal of Biological Chemistry 276 (2001)18361-18374). Thus, whether the pro-survival proteins restrain Baxactivation directly or indirectly remains uncertain.

Although Bax and Bak seem in most circumstances to be functionallyequivalent (Lindsten, T. et al., Molecular Cell 6 (2000) 1389-1399; Wei,M. C., et al., 2001 supra), substantial differences in their regulationwould be expected from their distinct localization in healthy cells.Unlike Bax, which is largely cytosolic, Bak resides in complexes on theouter membrane of mitochondria and on the endoplasmic reticulum ofhealthy cells (Wei, M. C., et al., 2000 supra; Zong, W. X., et al.,Journal of Cell Biology 162 (2003) 59-69). Nevertheless, on receipt ofcytotoxic signals, both Bax and Bak change conformation, and Baxtranslocates to the organellar membranes, where both Bax and Bak thenform homo-oligomers that can associate, leading to membranepermeabilization (Hsu. Y. T., et al., PNAS 94 (1997) 3668-3672; Wolter,K. G., et al., 1997 supra; Antonsson, B., et al., Journal of BiologicalChemistry 276 (2001) 11615-11623; Nechushtan. A. et al., Journal of CellBiology 153 (2001) 1265-1276: Wei, M. C., et al., 2001 supra; Mikhailov,V., et al., Journal of Biological Chemistry 278 (2003) 5367-5376).

There exist various Bcl-2 inhibitors, which all have the same propertyof inhibiting prosurvival members of the Bcl-2 family of proteins andare therefore promising candidates for the treatment of cancer. SuchBcl-2 inhibitors include, for example: Oblimersen, SPC-2996, RTA-402,Gossypol, AT-101, Obatoclax mesylate, A-371191, A-385358, A-438744,ABT-737, ABT-263, AT-101, BL-11, BL-193, GX-15-003, 2-MethoxyantimycinA3, HA-14-1. KF-67544, Purpurogallin, TP-TW-37, YC-137 and Z-24, and aredescribed, for example, in Zhai, D., et al., Cell Death andDifferentiation 13 (2006) 1419-1421.

SUMMARY OF THE INVENTION

The present invention is directed to a method of treating aproliferative disorder, the method comprising administering to a mammalin need thereof a therapeutically effective amount of a combination of aMEK inhibitor and a selective Bcl-2 inhibitor.

The present invention is further directed to a pharmaceutical productcomprising (i) a first composition comprising[3,4-Difluoro-2-(2-fluoro-4-iodoanilino)phenyl]{3-hydroxy-3-[(2S)-piperidin-2-yl]azetidin-1-yl}methanone(cobimetinib) or a pharmaceutically acceptable salt thereof, and (ii) asecond composition comprising4-(4-{[2-(4-chlorophenyl)-4,4-dimethylcyclohex-1-en-1-yl]methyl}piperazin-1-yl)-N-({3-nitro-4-[(tetrahydro-2H-pyran-4-ylmethyl)amino]phenyl}sulfonyl)-2-(1H-pyrrolo[2,3-b]pyridin-5-yloxy)benzamide(ABT-199) or a pharmaceutically acceptable salt thereof.

Other objects and features will be in part apparent and in part pointedout hereinafter.

BRIEF DESCRIPTION OF THE DRAWINGS

FIGS. 1A through 1L are graphs depicting in vitro cytotoxicity ofcobimetinib and venetoclax against AML cell lines. (FIG. 1A) The AMLcell lines were treated with cobimetinib or venetoclax at 0.001, 0.01,0.1 and 1.0 μM for 72 hrs. Calcusyn software was used to calculate theIC₅₀ values and combination index (CI) based on the luminescentintensity that correlated with number of viable cells determined by theCellTiter-Glo assay. P-ERK was determined using flow cytometry andrelative median fluorescence intensity (R-MFI) was determined using MFIof p-ERK. Response patterns 1-5 were shown. (FIGS. 1B through 1L) Growthcurves of representative cell lines from each response pattern.

FIGS. 2A, 2B, and 2C. Anti-leukemia activities of cobimetinib/venetoclaxagainst primary AML blasts. (FIG. 2A) Primary AML peripheral bloodmononuclear cells were cultured in serum-Free Expansion Medium (SFEM)supplemented with BIT 9500 Serum Substitute and cytokines including stemcell factor (100 ng/ml), Flt3 ligand (50 ng/ml), IL-3 (20 ng/ml) andG-CSF (20 ng/ml) as well as SRI (1 μM). After culture for 5 days, cellswere stained with CD45-PE. Annexin-V-APC and DAPI-. The apoptoticleukemia blasts (CD45dimAnnexin-V+) were determined by flow cytometry.Results were expressed as percentage of specific apoptosis calculated bythe formula: 100×(% apoptosis of treated cells−% apoptosis of controlcells)/(100−% apoptosis of control cells), or % growth inhibition ofcontrol using the viable cell counts determined by Annexin-/DAPI. (FIG.2B) Representative data from 3 AML samples were shown, for thosedisplaying synergy. MNCs isolated from patients with AML (100,000) orhealthy donors (50,000) were plated in methylcellulose medium (1mL/well; Cat. 04435; STEMCELL Technologies Inc., Vancouver, BC, Canada)in triplicate per condition. Colonies were scored after 2 weeks ofculture. (FIG. 2C). Clinical data and combination index values based onviable cell count. **p<0.01, ***p<0.001.

FIGS. 3A, 3B, 3C, 3D, and 3E demonstrate a Pharmacodynamic study ofunderlying mechanisms of cobimetinib/venetoclax combination. (FIGS. 3A,3B, 3C, and 3D) RPPA data demonstrate proteins differentially expressedin sensitive or resistant AML cell lines (to single drugs orcombination) treated with cobimetinib or/and venetoclax at 0.5×, 1× and2×IC₅₀ values for 24 hrs. Representative proteins that aredifferentially expressed between combination-sensitive andcombination-resistant cells were shown. (FIG. 3E) The Bcl-2:BIM complexwas measured by the MSD ELISA assay in AML cell lines, untreated,treated with venetoclax alone, treated with cobimetinib alone, ortreated with cobimetinib/venetoclax at 1×IC₅₀ values for 4 hrs.

FIGS. 4A, 4B, and 4C demonstrate Mass cytometry analysis ofintracellular proteins in cell sub-populations. Mononuclear cells fromprimary AML were treated with cobimetinib at 1.0 μM for 2 hrs followedby 10 minutes plus or minus stimulation with G-CSF (100 ng/ml). TheSPADE tree was generated using markers including CD7, CD117, CD123,CD64, CD34, CD26, CD45, TIM3, CD33, CD19, CD56, CD2, CD15, CD41, CD38,CD166, CD3, CD90, CD11b, CD135 and HLA-DR. FIG. 4A depictsrepresentative markers from among those markers tested. The grey-scalecolor represents the expression levels of each indicated protein. (FIG.4A) Bcl-2 family members at baseline in the gated stem/progenitor AMLcell populations (AML4295468: CD34+CD38+CD123+CD33+; AML 4366894:CD34+CD38-CD123+CD33+). (FIG. 4B) The median intensity of each proteinin the gated cell populations mentioned above. (FIG. 4C) Theintracellular signaling protein activation in the gated populationsmentioned above.

FIGS. 5A, 5B, 5C, 5D, and 5E demonstrate Anti-leukemia efficacy ofcobimetinib and venetoclax in OCI-AML3 and MOLM13 AML model in vivo.OCI-AML3/Luc/GFP cells (1×10⁶ per mouse) were injected intravenouslyinto NSG mice. (FIG. 5A) The luciferase intensity was quantified byserial bioluminescence imaging from 8 representative mice from 4 groupsat week 5 post injection. (FIG. 5B) Overall survival rate in each groupwas estimated by the Kaplan-Meier method. 1×10⁶ MOLM13-luci-GFP cellswere injected into NSGS mice. Leukemia engraftment was confirmed on day3 using Bioluminescence imaging (BLI). Mice were orally dosed daily withcobimetinib (10 mg/kg) or venetoclax (100 mg/kg) or in combination for14 days. Luciferase intensity was shown on day 17 (FIG. 5C). Human CD45engraftment in BM and spleen was determined by CyTOF. (FIG. 5D). Theviable cell count was measured using Vi-Cell. (FIG. 5E). **P: 0.01;***P: 0.001.

DESCRIPTION OF THE EMBODIMENT(S) OF THE INVENTION

The present invention is directed to a combination therapy involving aselective Bcl-2 inhibitor and a MEK inhibitor for the treatment of amammal, e.g., a human patient, in need of such a therapy. Pro-survivalmolecules including Bcl-2 play critical roles in leukemia transformationand chemoresistance. ABT-199 (also known as, and optionally referred toherein as, GDC-01′), or venetoclax) is an orally available BH3-mimeticthat binds with high affinity to Bcl-2, but lacks affinity for Bcl-X_(L)and Mcl-1. The anti-leukemia potency of venetoclax in acute myeloidleukemia (AML) models has recently been demonstrated (see, e.g., Pan etal., Cancer Discovery 2014). However, venetoclax poorly inhibits Mcl-1,causing resistance in leukemia cells that rely on Mcl-1 for survival.The RAF/MEK/ERK (MAPK) cascade is a major effector pathway in AML thatis activated by upstream mutant proteins such as FLT3, KIT and RAS.Additionally, the MAPK pathway regulates Bcl-2 family proteins bystabilizing anti-apoptotic Mcl-1 and inactivating pro-apoptotic BIM. Insome embodiments, the present invention is directed to a combinationtherapy that combines the anti-tumor effects of the concomitant Bcl-2and MAPK blockade by venetoclax in combination with MEK1/2 inhibitorcobimetinib.

In some embodiment, the mammal, e.g., a human patient, in need of thecombination therapy is suffering from cancer, such as acute myeloidleukemia. In some embodiments, the combination therapy involvesadministering a therapeutically effective amount of a selective Bcl-2inhibitor and a therapeutically effective amount of a MEK inhibitor forthe treatment of a mammal, e.g., a human patient, in need of such atherapy.

In some embodiments, the mammal, e.g., a human patient, in need of thecombination therapy is suffering from cancer, such as multiple myeloma.In some embodiments, the combination therapy involves administering atherapeutically effective amount of a selective Bcl-2 inhibitor and atherapeutically effective amount of a MEK inhibitor for the treatment ofa mammal, e.g., a human patient, in need of such a therapy.

In some embodiments, the selective Bcl-2 inhibitor comprises4-(4-{[2-(4-chlorophenyl)-4,4-dimethylcyclohex-1-en-1-yl]methyl}piperazin-1-yl)-N-({3-nitro-4-[(tetrahydro-2H-pyran-4-ylmethyl)amino]phenyl}sulfonyl)-2-(1H-pyrrolo[2,3-b]pyridin-5-yloxy)benzamide(also known as, and optionally referred to herein as, venetoclax, orABT-199, or GDC-0199) or a pharmaceutically acceptable salt thereof. Insome embodiments, the combination therapy of the present inventioninvolves administration of a therapeutically effective amount of4-(4-{[2-(4-chlorophenyl)-4,4-dimethylcyclohex-1-en-1-yl]methyl}piperazin-1-yl)-N-({3-nitro-4-[(tetrahydro-2H-pyran-4-ylmethyl)amino]phenyl}sulfonyl)-2-(1H-pyrrolo[2,3-b]pyridin-5-yloxy)benzamide(venetoclax, or ABT-199/GDC-0199) or a pharmaceutically acceptable saltthereof to a mammal, e.g., a human patient, in need thereof. Venetoclaxhas the following structure:

4-(4-{[2-(4-chlorophenyl)-4,4-dimethylcyclohex-1-en-1-yl]methyl)piperazin-1-yl)-N-({3-nitro-4-[(tetrahydro-2H-pyran-4-ylmethyl)amino]phenyl}sulfonyl)-2-(1H-pyrrolo[2,3-b]pyridin-1-yloxy)benzamide

In some embodiments, the MEK inhibitor comprises[3,4-difluoro-2-(2-fluoro-4-iodoanilino)phenyl]{3-hydroxy-3-[(2S)-piperidin-2-yl]azetidin-1-yl}methanone(also known as, and optionally referred to herein as, cobimetinib, orGDC-0973) or a pharmaceutically acceptable salt thereof. In someembodiments, the combination therapy of the present invention involvesadministration of a therapeutically effective amount of[3,4-difluoro-2-(2-fluoro-4-iodoanilino)phenyl]{3-hydroxy-3-[(2S)-piperidin-2-yl]azetidin-1-yl}methanone(cobimetinib, or GDC-0973) or a pharmaceutically acceptable salt thereofto a mammal, e.g., a human patient, in need thereof. Cobimetinib has thefollowing structure

[3,4-Difluoro-2-(2-fluoro-4-iodoanilino)phenyl](3-hydroxy-3-[(2S)-piperidin-2-yl]azetidin-1-yl)methanone

The name of this compound as generated using ACD/Labs naming software8.00 release, product version 8.08 is1-({3,4-difluoro-2-[(2-fluoro-4-iodophenyl)amino]phenyl}carbonyl)-3-[(2S)-piperidin-2-yl]azetidin-3-ol.

In some embodiments, the combination therapy comprises administering toa mammal, e.g., a human patient, in need of such a therapy atherapeutically effective amount of4-(4-{[2-(4-chlorophenyl)-4,4-dimethylcyclohex-1-en-1-yl]methyl}piperazin-1-yl)-N-({3-nitro-4-[(tetrahydro-2H-pyran-4-ylmethyl)amino]phenyl}sulfonyl)-2-(1H-pyrrolo[2,3-b]pyridin-5-yloxy)benzamide(ABT-199) or a pharmaceutically acceptable salt thereof and atherapeutically effective amount of[3,4-Difluoro-2-(2-fluoro-4-iodoanilino)phenyl]{3-hydroxy-3-[(2S)-piperidin-2-yl]azetidin-1-yl}methanone(cobimetinib) or a pharmaceutically acceptable salt thereof. The patientin need of the combination therapy of the invention may be sufferingfrom cancer. In some embodiments, the cancer is acute myeloid leukemia.In some embodiments, the cancer is multiple myeloma.

I. Definitions

The term “mammal” includes, but is not limited to, humans, mice, rats,guinea pigs, monkeys, dogs, cats, horses, cows, pigs, sheep, andpoultry. The term patient refers to a mammal, and in one embodiment, thepatient is a human male or a human female.

Herein, a “patient” (interchangeably termed “individual”) is a humanpatient. The patient may be a “cancer patient”, i.e. one who issuffering or at risk for suffering from one or more symptoms of cancer.A “subject” or an “individual” for purposes of treatment refers to anyanimal classified as a mammal, including humans, domestic and farmanimals, and zoo, sports, or pet animals, such as dogs, horses, cats,cows, etc. Preferably, the mammal is human.

A “population” of patients refers to a group of patients with cancer,such as in a clinical trial, or as seen by oncologists following FDAapproval for a particular indication, such as unresectable or metastaticmelanoma cancer therapy.

A “disorder” is any condition that would benefit from treatmentincluding, but not limited to, chronic and acute disorders or diseasesincluding those pathological conditions which predispose the mammal tothe disorder in question.

The terms “cell proliferative disorder” and “proliferative disorder”refer to disorders that are associated with some degree of abnormal cellproliferation. In one embodiment, the cell proliferative disorder iscancer. In one embodiment, the cell proliferative disorder is a tumor.

“Tumor,” as used herein, refers to all neoplastic cell growth andproliferation, whether malignant or benign, and all pre-cancerous andcancerous cells and tissues. The terms “cancer”, “cancerous”, “cellproliferative disorder”, “proliferative disorder” and “tumor” are notmutually exclusive as referred to herein.

The terms “cancer” and “cancerous” refer to or describe thephysiological condition in mammals that is typically characterized byunregulated cell growth. Examples of cancer include but are not limitedto, carcinoma, lymphoma, blastoma, sarcoma, and leukemia or lymphoidmalignancies. More particular examples of such cancers include, but notlimited to, squamous cell cancer (e.g., epithelial squamous cellcancer), lung cancer including small-cell lung cancer, non-small celllung cancer, adenocarcinoma of the lung and squamous carcinoma of thelung, cancer of the peritoneum, hepatocellular cancer, gastric orstomach cancer including gastrointestinal cancer and gastrointestinalstromal cancer, pancreatic cancer, glioblastoma, cervical cancer,ovarian cancer, liver cancer, bladder cancer, cancer of the urinarytract, hepatoma, breast cancer, colon cancer, rectal cancer, colorectalcancer, endometrial or uterine carcinoma, salivary gland carcinoma,kidney or renal cancer, prostate cancer, vulval cancer, thyroid cancer,hepatic carcinoma, anal carcinoma, penile carcinoma, melanoma,superficial spreading melanoma, lentigo maligna melanoma, acrallentiginous melanomas, nodular melanomas, multiple myeloma and B-celllymphoma (including low grade/follicular non-Hodgkin's lymphoma (NHL);small lymphocytic (SL) NHL; intermediate grade/follicular NHL;intermediate grade diffuse NHL; high grade immunoblastic NHL; high gradelymphoblastic NHL; high grade small non-cleaved cell NHL; bulky diseaseNHL; mantle cell lymphoma; AIDS-related lymphoma; and Waldenstrom'sMacroglobulinemia); chronic lymphocytic leukemia (CLL); acutelymphoblastic leukemia (ALL); hairy cell leukemia; chronic myeloblasticleukemia; and post-transplant lymphoproliferative disorder (PTLD), aswell as abnormal vascular proliferation associated with phakomatoses,edema (such as that associated with brain tumors), Meigs' syndrome,brain, as well as head and neck cancer, and associated metastases. Incertain embodiments, cancers that are amenable to treatment by theantibodies of the invention include breast cancer, colorectal cancer,rectal cancer, non-small cell lung cancer, glioblastoma, non-Hodgkinslymphoma (NHL), renal cell cancer, prostate cancer, liver cancer,pancreatic cancer, soft-tissue sarcoma, kaposi's sarcoma, carcinoidcarcinoma, head and neck cancer, ovarian cancer, mesothelioma, andmultiple myeloma. In some embodiments, the cancer is selected from:small cell lung cancer, glioblastoma, neuroblastomas, melanoma, breastcarcinoma, gastric cancer, colorectal cancer (CRC), and hepatocellularcarcinoma.

The term “treating” as used herein, unless otherwise indicated, meansreversing, alleviating, inhibiting the progress of, or preventing,either partially or completely, the growth of tumors, tumor metastases,or other cancer-causing or neoplastic cells in a patient. The object isto prevent or slow down (lessen) an undesired physiological change ordisorder, such as the growth, development or spread of cancer. Forpurposes of this invention, beneficial or desired clinical resultsinclude, but are not limited to, alleviation of symptoms, diminishmentof extent of disease, stabilized (i.e., not worsening) state of disease,delay or slowing of disease progression, amelioration or palliation ofthe disease state, and remission (whether partial or total), whetherdetectable or undetectable.

As used herein, the term “treatment” refers to clinical interventiondesigned to alter the natural course of the individual or cell beingtreated during the course of clinical pathology. Desirable effects oftreatment include decreasing the rate of disease progression,ameliorating or palliating the disease state, and remission or improvedprognosis. For example, an individual is successfully “treated” if oneor more symptoms associated with cancer are mitigated or eliminated,including, but are not limited to, reducing the proliferation of (ordestroying) cancerous cells, decreasing symptoms resulting from thedisease, increasing the quality of life of those suffering from thedisease, decreasing the dose of other medications required to treat thedisease, and/or prolonging survival of individuals. “Treatment” refersto both therapeutic treatment and prophylactic or preventative measures.“Treatment” can also mean prolonging survival as compared to expectedsurvival if not receiving treatment. Those in need of treatment includethose already having the condition or disorder, e.g., a patient withcancer.

The term “a method of treating” or its equivalent, when applied to, forexample, cancer refers to a procedure or course of action that isdesigned to reduce or eliminate the number of cancer cells in a patient,or to alleviate the symptoms of a cancer. “A method of treating” canceror another proliferative disorder does not necessarily mean that thecancer cells or other disorder will, in fact, be eliminated, that thenumber of cells or disorder will, in fact, be reduced, or that thesymptoms of a cancer or other disorder will, in fact, be alleviated.Often, a method of treating cancer will be performed even with a lowlikelihood of success, but which, given the medical history andestimated survival expectancy of a patient, is nevertheless deemed toinduce an overall beneficial course of action. The terms“co-administration” or “co-administering” refer to the administration ofsaid MEK inhibitor and said selective Bcl-2 inhibitor as two separateformulations or within one single formulation. The co-administration canbe simultaneous or sequential in either order. In one furtherembodiment, there is a time period while both (or all) active agentssimultaneously exert their biological activities. Said MEK inhibitor andsaid selective Bcl-2 inhibitor are co-administered either simultaneouslyor sequentially (e.g. via an intravenous (i.v.) through a continuousinfusion (one for the MEK inhibitor and eventually one for the Bcl-2inhibitor; or the Bcl-2 inhibitor is administered orally). When boththerapeutic agents are co-administered sequentially the agents areadministered in two separate administrations that are separated by a“specific period of time”. The term specific period of time is meantanywhere from 1 hour to 15 days. For example, one of the agents can beadministered within about 15, 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3,2, or 1 day, or 24, 23, 22, 21, 20, 19, 18, 17, 16, 15, 14, 13, 12, 11,10, 9, 8, 7, 6, 5, 4, 3, 2 or 1 hour from the administration of theother agent, and, in one embodiment, the specific period time is 10, 9,8, 7, 6, 5, 4, 3, 2, or 1 day, or 24, 23, 22, 21, 20, 19, 18, 17, 16,15, 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3, 2 or 1 hour.

To “inhibit” is to decrease or reduce an activity, function, and/oramount as compared to a reference.

For the purposes herein, a “previously treated” cancer patient hasreceived prior cancer therapy. A “previously treated” unresectable ormetastatic melanoma patient has received prior therapy for unresectableor metastatic melanoma.

A “cancer medicament” is a drug effective for treating cancer.

The terms “orally deliverable”. “oral administration” and “orallyadministered” herein refer to administration to a subject per os (p.o.),that is, administration wherein the composition is immediatelyswallowed, for example with the aid of a suitable volume of water orother potable liquid. “Oral administration” is distinguished herein fromintraoral administration, e.g., sublingual or buccal administration ortopical administration to intraoral tissues such as periodontal tissues,that does not involve immediate swallowing of the composition.

The term “simultaneously” means at the same time or within a shortperiod of time, usually less than 1 hour.

A dosing period as used herein is meant a period of time, during whicheach therapeutic agent has been administered at least once. A dosingcycle is usually about 1, 2, 3, 4, 5, 6.7, 8, 9, 10, 11, 12, 13, 14, 15,16, 17, 18.19, 20, 21, 22, 23.24, 25, 26, 27, 28, 29, or 30 days, and,in one embodiment, 6, 7, 8, 9, 10, 11, 12, 13, or 14 days, for example,7 or 14 days.

In certain embodiments, a dosing period is a dosing cycle.

It is self-evident that the pharmaceutically active agents areadministered to the patient in a “therapeutically effective amount” (orsimply “effective amount”) which is the amount of the respectivecompound or combination that will elicit the biological or medicalresponse of a tissue, system, animal or human that is being sought bythe researcher, veterinarian, medical doctor or other clinician. Theadministration of an effective amount of a pharmaceutically active agentcan be a single administration or split dose administration. A “splitdose administration” is meant an effective amount is a split intomultiple doses, preferably 2, and administered within 1 or 2 days. Forexample, if 100 mg of a selective Bcl-2 inhibitor is deemed effective,it can be administered in one 100 mg administration or two 50 mgadministrations. Split dose administration is sometimes desirable at thebeginning of a dosing period to reduce side effects. When an effectiveamount is administered in split dosing, it is still considered oneadministration of an effective amount. For example, when 100 mg is theeffective amount of a selective Bcl-2 inhibitor and that amount isadministered in two 50 mg doses over a period of time, e.g. 2 days, onlyone effective amount is administered during that period of time.

The term “pharmaceutical formulation” refers to a sterile preparationthat is in such form as to permit the biological activity of themedicament to be effective, and which contains no additional componentsthat are unacceptably toxic to a subject to which the formulation wouldbe administered.

As used herein, a “pharmaceutically acceptable carrier” is intended toinclude any and all material compatible with pharmaceuticaladministration including solvents, dispersion media, coatings,antibacterial and antifungal agents, isotonic and absorption delayingagents, and other materials and compounds compatible with pharmaceuticaladministration. A non-limiting list of exemplary pharmaceuticallyacceptable carriers is a buffer, excipient, stabilizer, or preservative.Except insofar as any conventional media or agent is incompatible withthe active compound, use thereof in the compositions of the invention iscontemplated. Supplementary active compounds can also be incorporatedinto the compositions.

The phrase “pharmaceutically acceptable salt” as used herein, refers topharmaceutically acceptable organic or inorganic salts of a compound.Exemplary salts include, but are not limited, to bismesylate, sulfate,citrate, acetate, oxalate, chloride, bromide, iodide, nitrate,bisulfate, phosphate, acid phosphate, isonicotinate, lactate,salicylate, acid citrate, tartrate, oleate, tannate, pantothenate,bitartrate, ascorbate, succinate, maleate, gentisinate, fumarate,gluconate, glucuronate, saccharate, formate, benzoate, glutamate,methanesulfonate “mesylate”, ethanesulfonate, benzenesulfonate,p-toluenesulfonate, and pamoate (i.e.,1,1′-methylene-bis-(2-hydroxy-3-naphthoate)) salts. A pharmaceuticallyacceptable salt may involve the inclusion of another molecule such as anacetate ion, a succinate ion or other counter ion. The counter ion maybe any organic or inorganic moiety that stabilizes the charge on theparent compound. Furthermore, a pharmaceutically acceptable salt mayhave more than one charged atom in its structure. Instances wheremultiple charged atoms are part of the pharmaceutically acceptable saltcan have multiple counter ions. Hence, a pharmaceutically acceptablesalt can have one or more charged atoms and/or one or more counter ion.

The desired pharmaceutically acceptable salt may be prepared by anysuitable method available in the art. For example, treatment of the freebase with an inorganic acid, such as hydrochloric acid, hydrobromicacid, sulfuric acid, nitric acid, methanesulfonic acid, phosphoric acidand the like, or with an organic acid, such as acetic acid, maleic acid,succinic acid, mandelic acid, fumaric acid, malonic acid, pyruvic acid,oxalic acid, glycolic acid, salicylic acid, a pyranosidyl acid, such asglucuronic acid or galacturonic acid, an alpha hydroxy acid, such ascitric acid or tartaric acid, an amino acid, such as aspartic acid orglutamic acid, an aromatic acid, such as benzoic acid or cinnamic acid,a sulfonic acid, such as p-toluenesulfonic acid or ethanesulfonic acid,or the like. Acids which are generally considered suitable for theformation of pharmaceutically useful or acceptable salts from basicpharmaceutical compounds are discussed, for example, by P. Stahl et al,Camille G. (eds.) Handbook of Pharmaceutical Salts. Properties,Selection and Use. (2002) Zurich: Wiley-VCH; S. Berge et al, Journal ofPharmaceutical Sciences (1977) 66(1) 1 19; P. Gould, International J. ofPharmaceutics (1986) 33 201217; Anderson et al, The Practice ofMedicinal Chemistry (1996), Academic Press, New York; Remington'sPharmaceutical Sciences, 18.sup.th ed., (1995) Mack Publishing Co.,Easton Pa.; and in The Orange Book (Food & Drug Administration,Washington, D.C, on their website). These disclosures are incorporatedherein by reference thereto.

II. Selective Bcl-2 Inhibitor

The combination therapy of the present invention involves theadministration of a selective Bcl-2 inhibitor. Methods of treatmentusing selective Bcl-2 inhibitors are disclosed in U.S. Publication No.2012/0129853, the disclosure of which is hereby incorporated byreference as if set forth in its entirety. In this regard, a selectiveBcl-2 inhibitor is one which selectively binds to a particular proteinwithin the Bcl-2 family. In some embodiments, the combination therapy ofthe present invention involves the administration of a selective Bcl-2inhibitor that selectively inhibits Bcl-2 protein. For example,4-(4-{[2-(4-chlorophenyl)-4,4-dimethylcyclohex-1-en-1-yl]methyl}piperazin-1-yl)-N-({3-nitro-4-[(tetrahydro-2H-pyran-4-ylmethyl)amino]phenyl}sulfonyl)-2-(1H-pyrrolo[2,3-b]pyridin-5-yloxy)benzamide(also known as, and optionally referred to as, venetoclax, orABT-199/GDC-0199) is an orally available, potent and highly selectiveinhibitor of Bcl-2, a member of the Bcl-2 family of regulator proteinsthat regulate apoptosis. ABT-199 selectively binds to and elicits aresponse on Bcl-2 proteins at much lower concentrations than thoserequired to bind to and elicit a response on Bcl-x_(L). As such, whenABT-199 is administered to the patient, the inhibitor is more prone toinhibit Bcl-2, rather than Bcl-x_(L). ABT-199 tends to have acompetitive binding affinity (Ki) for Bcl-2 that is at least about 500,at least about 1000, at least about 2000, at least about 2500, at leastabout 3000, at least about 3500, and at least about 4000 times less thanthe binding affinity for Bcl-x_(L). As such, even at low concentrations(i.e., picomolar concentrations), ABT-199 will bind to and inhibit theBcl-2 protein.

In some embodiments, the selective Bcl-2 inhibitor comprises4-(4-{[2-(4-chlorophenyl)-4,4-dimethylcyclohex-1-en-1-yl]methyl}piperazin-1-yl)-N-({3-nitro-4-[(tetrahydro-2H-pyran-4-ylmethyl)amino]phenyl}sulfonyl)-2-(1H-pyrrolo[2,3-b]pyridin-5-yloxy)benzamide(venetoclax, or ABT-199/GDC-0199) or a pharmaceutically acceptable saltthereof. In some embodiments, the combination therapy of the presentinvention involves administration of a therapeutically effective amountof4-(4-{[2-(4-chlorophenyl)-4,4-dimethylcyclohex-1-en-1-yl]methyl}piperazin-1-yl)-N-({3-nitro-4-[(tetrahydro-2H-pyran-4-ylmethyl)amino]phenyl}sulfonyl)-2-(1H-pyrrolo[2,3-b]pyridin-5-yloxy)benzamide(venetoclax, or ABT-199/GDC-0199) or a pharmaceutically acceptable saltthereof to a mammal, e.g., a human patient, in need thereof. Venetoclaxhas the following structure:

4-(4-{[2-(4-chlorophenyl)-4,4-dimethylcyclohex-1-en-1-yl]methyl)piperazin-1-yl)-N-((3-nitro-4-[(tetrahydro-2H-pyran-4-ylmethyl)amino]phenyl}sulfonyl)-2-(1H-pyrrolo[2,3-b]pyridin-5-yloxy)benzamide

Venetoclax (or ABT-199/GDC-0199) may be formulated in itsparent-compound form (i.e., as a free base), in a pharmaceuticallyacceptable salt form of the compound, or a combination of theparent-compound form and the pharmaceutically acceptable salt form.Additional suitable forms include the hydrate or solvated forms ofABT-199. In some embodiments, the ABT-199 may be a crystalline polymorphsuitable for incorporation into a pharmaceutical composition furthercomprising a pharmaceutical acceptable excipient. Salts and crystallineforms of ABT-199 are disclosed in U.S. Publication No. 2012/0157470, thedisclosure of which is hereby incorporated by reference as if set forthin its entirety. The phrase “pharmaceutically acceptable salt(s)”, asused herein, means those salts of ABT-199 that are safe and effectivefor administration to a patient and that do not adversely affect thetherapeutic qualities of the compound. Pharmaceutically acceptable saltsinclude salts of acidic or basic groups present in compounds of theinvention. Salts of ABT-199 can be prepared during isolation orfollowing purification of the compounds.

Acid addition salts are those derived from reaction of Venetoclax (orABT-199/GDC-0199) with an acid. For example, salts including theacetate, acid phosphate, adipate, alginate, ascorbate, bicarbonate,citrate, aspartate, benzoate, benzenesulfonate (besylate), bisulfate,bitartrate, butyrate, camphorate, camphorsulfonate, citrate,digluconate, ethanesulfonate, ethanedisulfonate, formate, fumarate,gentisinate, glycerophosphate, gluconate, glucaronate, glutamate,hemisulfate, heptanoate, hexanoate, hydrobromide, hydrochloride,hydroiodide, isonicotinate, 1-hydroxy-2-naphthoate, lactate,lactobionate, malate, maleate, malonate, mesitylenesulfonate,methanesulfonate, naphthalenesulfonate, nicotinate, nitrate, oxalate,p-toluenesulfonate, pamoate (i.e.,1,1′-methylene-bis-(2-hydroxy-3-naphthoate), pantothenate, pectinate,persulfate, phosphate, picrate, propionate, saccharate, salicylate,succinate, sulfate, tartrate, thiocyanate, trichloroacetate,trifluoroacetate, para-toluenesulfonate and undecanoate salts of acompound of ABT-199 can be used in a composition of the invention. Basicaddition salts, including those derived from reaction of ABT-199 withthe bicarbonate, carbonate, hydroxide or phosphate of cations such asaluminum, lithium, sodium, potassium, calcium, zinc, and magnesium, canlikewise be used. (For a review on pharmaceutically acceptable saltssee, e.g., Berge et al., 66J. Pharm. Sci., 1-19 (1977), incorporatedherein by reference, in its entirety.)

Venetoclax (or ABT-199/GDC-0199) or a pharmaceutically acceptable saltthereof may present in a dosage form in an amount that can betherapeutically effective when the composition is administered to asubject in need thereof according to an appropriate regimen. Dosageamounts are expressed herein as parent-compound-equivalent amountsunless the context requires otherwise. Typically, a unit dose (theamount administered at a single time), which can be administered at anappropriate frequency, e.g., twice daily to once weekly, is about 10 toabout 1,000 mg, depending on the compound in question. Where frequencyof administration is once daily (q.d.), unit dose and daily dose are thesame. Illustratively, the unit dose is typically about 25 to about 1,000mg, more typically about 50 to about 500 mg, for example about 50, about100, about 150, about 200, about 250, about 300, about 350, about 400,about 450 or about 500 mg. Where the dosage form comprises a capsuleshell enclosing the dosage form, e.g., a solid dispersion, or a tabletwherein the dosage form (e.g., a solid dispersion) is formulated withother ingredients, a unit dose can be deliverable in a single dosageform or a plurality of dosage forms, most typically 1 to about 10 dosageforms.

The “therapeutically effective amount” of the venetoclax (orABT-199/GDC-0199) or the pharmaceutically acceptable salt thereof refersto that amount of the compound being administered sufficient to preventdevelopment of or alleviate to some extent one or more of the symptomsof the condition or disorder being treated. Therapeutically effectiveamounts of ABT-199 depend on the recipient of the treatment, thedisorder being treated and the severity thereof, the compositioncontaining the compound, the time of administration, the route ofadministration, the duration of treatment, the compound potency, itsrate of clearance and whether or not another drug is co-administered.Generally, the methods of the current invention involve administering adose of the selective Bcl-2 inhibitor ranging from about 0.001 mg/kg toabout 1000 mg/kg. In one embodiment, the methods involve administering adose of selective Bcl-2 inhibitor ranging from about 0.01 mg/kg to about500 mg/kg. In a further embodiment, the methods involve administering adose of ABT-199 ranging from about 0.1 mg/kg to about 300 mg/kg.

The methods of the current invention may have illustrated improvedefficacy in treating disease states compared to methods currently knownwithin the art due to the fact that ABT-199 may selectively inhibit theBcl-2 protein. The Bcl-2 family of proteins is a group of proteins thathave regulatory effects on many developmental and homeostasis functions,such as apoptosis (programmed cell death). The Bcl-2 family includesother proteins include Bcl-x_(L) and Bcl-w. However, inhibition of theBcl-x_(L) protein has been shown to have an adverse impact on plateletcounts, in some cases resulting in thrombocytopenia. The selective Bcl-2inhibitor compounds have shown a higher binding affinity (as evidencedby lower Ki values) for Bcl-2 compared to other Bcl-2 family proteins,such as Bcl-x_(L) and Bcl-w. As such, the methods of the currentinvention provide the advantages of inhibition of the Bcl-2 protein,with a decreased risk of the adverse effects associated with Bcl-x_(L)and Bcl-w inhibition, such as thrombocytopenia. This may allow for amore tolerable combination with other drugs such as cobimetinib.Additionally, ABT-199 is a more potent Bcl-2 inhibitor than some Bcl-2inhibitors known in the art. Finally, it has been observed that acutemyeloid leukemia cells are more dependent on Bcl-2 than Bcl-X_(L) forsurvival, which is an unexpected finding in this field. The rationale ofcombination with cobimetinib is to treat tumors in which Bcl-2 and Mcl-1are co-expressed.

The binding affinity for the various proteins is measured as a value ofKi, which represents the amount of the compound required to inhibit aphysiologic process or compound (such as a protein) by 50%. See U.S.Publication No. 2012/0129853, the disclosure of which is herebyincorporated by reference as if set forth in its entirety. The selectiveBcl-2 compounds used in the methods of the current invention generallyhave a binding affinity (Ki) of less than about 1 micromolar, less thanabout 500 nanomolar, less than about 400 nanomolar, less than about 300nanomolar, less than about 200 nanomolar, less than about 100 nanomolar,less than about 50 nanomolar, less than about 25 nanomolar, less thanabout 10 nanomolar, less than about 5 nanomolar, less than about 1nanomolar, less than about 900 picomolar, less than about 800 picomolar,less than about 700 picomolar, less than about 600 picomolar, less thanabout 500 picomolar, less than about 400 picomolar, less than about 300picomolar, less than about 200 picomolar, and less than about 100picomolar to Bcl-2.

III. Cobimetinib

Cobimetinib (also known as, and optionally referred to herein as,GDC-0973) is an orally available, potent, and highly selective inhibitorof MEK1 and MEK2. MEK1 and MEK2 are central components of the RAS/RAFpathway. Selective MEK inhibitors, including cobimetinib, are disclosedin U.S. Pat. No. 7,803,839, the disclosure of which is herebyincorporated by reference as if set forth in its entirety.

In some embodiments, the MEK inhibitor comprises[3,4-difluoro-2-(2-fluoro-4-iodoanilino)phenyl]{3-hydroxy-3-[(2S)-piperidin-2-yl]azetidin-1-yl}methanone(cobimetinib, or GDC-0973) or a pharmaceutically acceptable saltthereof. In some embodiments, the combination therapy of the presentinvention involves administration of a therapeutically effective amountof[3,4-difluoro-2-(2-fluoro-4-iodoanilino)phenyl]{3-hydroxy-3-[(2S)-piperidin-2-yl]azetidin-1-yl}methanone(cobimetinib, or GDC-0973) or a pharmaceutically acceptable salt thereofto a mammal, e.g., a human patient, in need thereof. Cobimetinib has thefollowing structure.

[3,4-Difluoro-2-(2-fluoro-4-iodoanilino)phenyl]{3-hydroxy-3-[(2S)-piperidin-2-yl]azetidin-1-yl}methanone

Cobimetinib may be formulated in its parent-compound form (i.e., as afree base), in a pharmaceutically acceptable salt form of the compound,or a combination of the parent-compound form and the pharmaceuticallyacceptable salt form. Additional suitable forms include the hydrate orsolvated forms of cobimetinib. In some embodiments, the cobimetinib maybe a crystalline polymorph suitable for incorporation into apharmaceutical composition further comprising a pharmaceuticalacceptable excipient. Salts and crystalline forms of cobimetinib aredisclosed in U.S. Pat. No. 7,803,839 and International Application No.PCT/EP2013/067050 (published as WO 2014/027056), the disclosures ofwhich are hereby incorporated by reference as if set forth in theirentirety. The phrase “pharmaceutically acceptable salt(s)”, as usedherein, means those salts of cobimetinib that are safe and effective foradministration to a patient and that do not adversely affect thetherapeutic qualities of the compound. Pharmaceutically acceptable saltsinclude salts of acidic or basic groups present in compounds of theinvention. Salts of cobimetinib can be prepared during isolation orfollowing purification of the compounds.

Pharmaceutically acceptable salts are described herein and known in theart. Exemplary salts include, but are not limited, to sulfate, citrate,acetate, oxalate, chloride, bromide, iodide, nitrate, bisulfate,phosphate, acid phosphate, isonicotinate, lactate, salicylate, acidcitrate, tartrate, oleate, tannate, pantothenate, bitartrate, ascorbate,succinate, maleate, gentisinate, fumarate, gluconate, glucuronate,saccharate, formate, benzoate, glutamate, methanesulfonate “mesylate”,ethanesulfonate, benzenesulfonate, p-toluenesulfonate, and pamoate(i.e., 1,1′-methylene-bis-(2-hydroxy-3-naphthoate)) salts. Apharmaceutically acceptable salt may involve the inclusion of anothermolecule such as an acetate ion, a succinate ion or other counter ion.The counter ion may be any organic or inorganic moiety that stabilizesthe charge on the parent compound. Furthermore, a pharmaceuticallyacceptable salt may have more than one charged atom in its structure.Instances where multiple charged atoms are part of the pharmaceuticallyacceptable salt can have multiple counter ions. Hence, apharmaceutically acceptable salt can have one or more charged atomsand/or one or more counter ion. If the compound is a base, the desiredpharmaceutically acceptable salt may be prepared by any suitable methodavailable in the art, for example, treatment of the free base with aninorganic acid, such as hydrochloric acid, hydrobromic acid, sulfuricacid, nitric acid, methanesulfonic acid, phosphoric acid and the like,or with an organic acid, such as acetic acid, maleic acid, succinicacid, mandelic acid, fumaric acid, malonic acid, pyruvic acid, oxalicacid, glycolic acid, salicylic acid, a pyranosidyl acid, such asglucuronic acid or galacturonic acid, an alpha hydroxy acid, such ascitric acid or tartaric acid, an amino acid, such as aspartic acid orglutamic acid, an aromatic acid, such as benzoic acid or cinnamic acid,a sulfonic acid, such as p-toluenesulfonic acid or ethanesulfonic acid,or the like. Acids which are generally considered suitable for theformation of pharmaceutically useful or acceptable salts from basicpharmaceutical compounds are discussed, for example, by: P. Stahl et al,Camille G. (eds.) Handbook of Pharmaceutical Salts. Properties,Selection and Use. (2002) Zurich: Wiley-VCH; S. Berge et al, Journal ofPharmaceutical Sciences (1977) 66(1) 1 19; P. Gould, International J. ofPharmaceutics (1986) 33 201217; Anderson et al, The Practice ofMedicinal Chemistry (1996), Academic Press, New York; Remington'sPharmaceutical Sciences. 18th ed., (1995) Mack Publishing Co., EastonPa.; and in The Orange Book (Food & Drug Administration. Washington,D.C, on their website). If the compound is an acid, the desiredpharmaceutically acceptable salt may be prepared by any suitable method,for example, treatment of the free acid with an inorganic or organicbase, such as an amine (primary, secondary or tertiary), an alkali metalhydroxide or alkaline earth metal hydroxide, or the like. Illustrativeexamples of suitable salts include, but are not limited to, organicsalts derived from amino acids, such as glycine and arginine, ammonia,primary, secondary, and tertiary amines, and cyclic amines, such aspiperidine, morpholine and piperazine, and inorganic salts derived fromsodium, calcium, potassium, magnesium, manganese, iron, copper, zinc,aluminum and lithium.

Cobimetinib or a pharmaceutically acceptable salt thereof may present ina dosage from in an amount that can be therapeutically effective whenthe composition is administered to a subject in need thereof accordingto an appropriate regimen. Dosage amounts are expressed herein asparent-compound-equivalent amounts unless the context requiresotherwise. Typically, a unit dose (the amount administered at a singletime), which can be administered at an appropriate frequency, e.g.,twice daily to once weekly, is about 10 to about 1,000 mg, depending onthe compound in question. Where frequency of administration is oncedaily (q.d.), unit dose and daily dose are the same. Illustratively, theunit dose is typically about 25 to about 1,000 mg, more typically about50 to about 500 mg, for example about 50, about 100, about 150, about200, about 250, about 300, about 350, about 400, about 450 or about 500mg. Where the dosage form comprises a capsule shell enclosing the dosageform, e.g., a solid dispersion, or a tablet wherein the dosage form,e.g., a solid dispersion is formulated with other ingredients, a unitdose can be deliverable in a single dosage form or a plurality of dosageforms, most typically 1 to about 10 dosage forms.

The “therapeutically effective amount” of cobimetinib or thepharmaceutically acceptable salt thereof refers to that amount of thecompound being administered sufficient to prevent development of oralleviate to some extent one or more of the symptoms of the condition ordisorder being treated. Therapeutically effective amounts of cobimetinibdepend on the recipient of the treatment, the disorder being treated andthe severity thereof, the composition containing the compound, the timeof administration, the route of administration, the duration oftreatment, the compound potency, its rate of clearance and whether ornot another drug is co-administered. Generally, the methods of thecurrent invention involve administering a dose of cobimetinib rangingfrom about 0.001 mg/kg to about 1000 mg/kg. In one embodiment, themethods involve administering a dose of cobimetinib ranging from about0.01 mg/kg to about 500 mg/kg. In a further embodiment, the methodsinvolve administering a dose of cobimetinib ranging from about 0.1 mg/kgto about 300 mg/kg.

IV. Pharmaceutical Formulations

Typically, the concentration of drug or combination of drugs in thepharmaceutical formulation is at least about 1%, e.g., about 1% to about50%, by parent-compound-equivalent weight, but lower and higherconcentrations can be acceptable or achievable in specific cases.Illustratively, the drug concentration in various embodiments is atleast about 2%, e.g., about 2% to about 50%, or at least about 5%, e.g.,about 5% to about 40%, for example about 5%, about 10%, about 15%, about20%, about 25%, about 30%, about 35% or about 40%, byparent-compound-equivalent weight. In some embodiments, the drugconcentration may be between about 5% and about 15%, such as betweenabout 5% and about 12%, such as about 5%, about 6%, about 7%, about 8%,about 9%, about 10%, about 11%, or about 12%.

Orally deliverable solid dosage forms of the invention include but arenot limited to capsules, dragees, granules, pills, powders and tablets.Excipients commonly used to formulate such dosage forms includeencapsulating materials or formulation additives such as absorptionaccelerators, antioxidants, binders, buffers, coating agents, coloringagents, diluents, disintegrating agents, emulsifiers, extenders,fillers, flavoring agents, humectants, lubricants, preservatives,propellants, releasing agents, sterilizing agents, sweeteners,solubilizers and mixtures thereof. Many excipients have two or morefunctions in a pharmaceutical composition. Characterization herein of aparticular excipient as having a certain function, e.g., diluent,disintegrant, binding agent, etc., should not be read as limiting tothat function. Further information on excipients can be found instandard reference works such as Handbook of Pharmaceutical Excipients,3rd ed. (Kibbe, ed. (2000), Washington: American PharmaceuticalAssociation).

In some embodiments, a suitable formulation may be prepared as a soliddispersion, e.g., by a melting-extrusion process or by a solventevaporation process. The solid dispersion may be administered to apatient in need thereof, or the solid dispersion may be tabletted withfurther pharmaceutically acceptable excipients.

The melting-extrusion process (meltrex) is disclosed in U.S. PublicationNo. 2012/0108590, the disclosure of which is hereby incorporated byreference as if set forth in its entirety. The meltrex processcomprises: (a) subjecting to elevated temperature (i) an activepharmaceutical ingredient (API) or a pharmaceutically acceptable saltthereof. (ii) a pharmaceutically acceptable water-soluble polymericcarrier and (iii) a pharmaceutically acceptable surfactant to provide anextrudable semi-solid mixture; (b) extruding the semi-solid mixture, forexample through a die; and (c) cooling the resulting extrudate toprovide a solid matrix comprising the polymeric carrier and thesurfactant and having the compound or salt thereof dispersed in anessentially non-crystalline form therein. A “melt” herein is a liquid orsemi-solid (e.g., rubbery) state induced by elevated temperature whereinit is possible for a first component to become homogeneously distributedin a matrix comprising a second component. Typically, the second(matrix) component, for example a polymeric carrier, is in such a stateand other components, for example including a compound of Formula I or asalt thereof, dissolve in the melt, thus forming a solution. By“elevated temperature” herein is meant a temperature above a softeningpoint of the polymeric carrier, as affected by other components ifpresent, such as plasticizers or surfactants.

The solvent evaporation process is disclosed in U.S. Publication No.20120277210, the disclosure of which is hereby incorporated by referenceas if set forth in its entirety. The solvent evaporation processcomprises: (a) dissolving (i) an active pharmaceutical ingredient (API)or a pharmaceutically acceptable salt thereof, (ii) a pharmaceuticallyacceptable water-soluble polymeric carrier and (iii) a pharmaceuticallyacceptable surfactant in a suitable solvent; and (b) removing thesolvent to provide a solid matrix comprising the polymeric carrier andthe surfactant and having the compound or salt thereof dispersed in anessentially non-crystalline form therein.

Suitable diluents illustratively include, either individually or incombination, lactose, including anhydrous lactose and lactosemonohydrate; lactitol; maltitol; mannitol; sorbitol; xylitol; dextroseand dextrose monohydrate; fructose; sucrose and sucrose-based diluentssuch as compressible sugar, confectioner's sugar and sugar spheres;maltose; inositol hydrolyzed cereal solids; starches (e.g., corn starch,wheat starch, rice starch, potato starch, tapioca starch, etc.), starchcomponents such as amylose and dextrates, and modified or processedstarches such as pregelatinized starch; dextrins; celluloses includingpowdered cellulose, microcrystalline cellulose, silicifiedmicrocrystalline cellulose, food grade sources of α- and amorphouscellulose and powdered cellulose, and cellulose acetate; calcium saltsincluding calcium carbonate, tribasic calcium phosphate, dicalciumphosphate (e.g., dibasic calcium phosphate dihydrate), monobasic calciumsulfate monohydrate, calcium sulfate and granular calcium lactatetrihydrate; magnesium carbonate; magnesium oxide; bentonite; kaolin;sodium chloride; and the like. Such diluents, if present, typicallyconstitute in total about 1% to about 95%, for example about 5% to about50%, or about 10% to about 30%, by weight of the composition. Thediluent or diluents selected preferably exhibit suitable flow propertiesand, where tablets are desired, compressibility.

Microcrystalline cellulose and silicified microcrystalline cellulose areparticularly useful diluents, and are optionally used in combinationwith a water-soluble diluent such as mannitol. Illustratively, asuitable weight ratio of microcrystalline cellulose or silicifiedmicrocrystalline cellulose to mannitol is about 10:1 to about 1:1, butratios outside this range can be useful in particular circumstances.

Suitable disintegrants include, either individually or in combination,polymeric materials such as starches including pregelatinized starch andsodium starch glycolate; clays; magnesium aluminum silicate;cellulose-based disintegrants such as powdered cellulose,microcrystalline cellulose, methylcellulose, low-substitutedhydroxypropylcellulose, carmellose, carmellose calcium, carmellosesodium and croscarmellose sodium; alginates; povidone; crospovidone;polacrilin potassium; gums such as agar, guar, locust bean, karaya,pectin and tragacanth gums; colloidal silicon dioxide; and the like. Oneor more disintegrants, if present, typically constitute in total about0.2% to about 30%, for example about 0.5% to about 20%, or about 1% toabout 10%, by weight of the composition.

Sodium starch glycolate is a particularly useful disintegrant, andtypically constitutes in total about 1% to about 20%, for example about2% to about 15%, or about 5% to about 10%, by weight of the composition.

Binding agents or adhesives are useful excipients, particularly wherethe composition is in the form of a tablet. Such binding agents andadhesives should impart sufficient cohesion to the blend being tabletedto allow for normal processing operations such as sizing, lubrication,compression and packaging, but still allow the tablet to disintegrateand the composition to be absorbed upon ingestion. Suitable bindingagents and adhesives include, either individually or in combination,acacia; tragacanth; glucose; polydextrose; starch includingpregelatinized starch; gelatin; modified celluloses includingmethylcellulose, carmellose sodium, hydroxypropylmethylcellulose (HPMC),hydroxypropylcellulose, hydroxyethylcellulose and ethylcellulose;dextrins including maltodextrin; zein; alginic acid and salts of alginicacid, for example sodium alginate; magnesium aluminum silicate;bentonite: polyethylene glycol (PEG); polyethylene oxide; guar gum;polysaccharide acids; polyvinylpyrrolidone (povidone or PVP), forexample povidone K-15, K-30 and K-29/32; polyacrylic acids (carbomers);polymethacrylates; and the like. One or more binding agents and/oradhesives, if present, typically constitute in total about 0.5% to about25%, for example about 1% to about 15%, or about 1.5% to about 10%, byweight of the composition.

Povidone and hydroxypropylcellulose, either individually or incombination, are particularly useful binding agents for tabletformulations, and, if present, typically constitute about 0.5% to about15%, for example about 1% to about 10%, or about 2% to about 8%, byweight of the composition.

Wetting agents, e.g., solubilizers, can be added to the formulation ifdesired, in addition to the surfactant component of the soliddispersion. Non-limiting examples of surfactants that can be used aswetting agents include, either individually or in combination,quaternary ammonium compounds, for example benzalkonium chloride,benzethonium chloride and cetylpyridinium chloride; dioctyl sodiumsulfosuccinate; polyoxyethylene alkylphenyl ethers, for examplenonoxynol 9, nonoxynol 10 and octoxynol 9; poloxamers (polyoxyethyleneand polyoxypropylene block copolymers); polyoxyethylene fatty acidglycerides and oils, for example polyoxyethylene (8) caprylic/capricmono- and diglycerides, polyoxyethylene (35) castor oil andpolyoxyethylene (40) hydrogenated castor oil; polyoxyethylene alkylethers, for example ceteth-10, laureth-4, laureth-23, oleth-2, oleth-10,oleth-20, steareth-2, steareth-10, steareth-20, steareth-100 andpolyoxyethylene (20) cetostearyl ether; polyoxyethylene fatty acidesters, for example polyoxyethylene (20) stearate, polyoxyethylene (40)stearate and polyoxyethylene (100) stearate; sorbitan esters, forexample sorbitan monolaurate, sorbitan monooleate, sorbitanmonopalmitate and sorbitan monostearate; polyoxyethylene sorbitanesters, for example polysorbate 20 and polysorbate 80; propylene glycolfatty acid esters, for example propylene glycol laurate; sodium laurylsulfate; fatty acids and salts thereof, for example oleic acid, sodiumoleate and triethanolamine oleate; glyceryl fatty acid esters, forexample glyceryl monooleate, glyceryl monostearate and glycerylpalmitostearate; α-tocopherol polyethylene glycol (1000) succinate(TPGS); tyloxapol; and the like. One or more wetting agents, if present,typically constitute in total about 0.1% to about 15%, for example about0.2% to about 10%, or about 0.5% to about 7%, by weight of thecomposition, excluding surfactant present in the solid dispersion.

Nonionic surfactants, more particularly poloxamers, are examples ofwetting agents that can be useful herein. Illustratively, a poloxamersuch as Pluronic™ F127, if present, can constitute about 0.1% to about10%, for example about 0.2% to about 7%, or about 0.5% to about 5%, byweight of the composition, excluding surfactant present in the soliddispersion.

Lubricants reduce friction between a tableting mixture and tabletingequipment during compression of tablet formulations. Suitable lubricantsinclude, either individually or in combination, glyceryl behenate;stearic acid and salts thereof, including magnesium, calcium and sodiumstearates; hydrogenated vegetable oils; glyceryl palmitostearate; talc;waxes; sodium benzoate; sodium acetate, sodium fumarate; sodium stearylfumarate; PEGs (e.g., PEG 4000 and PEG 6000), poloxamers; polyvinylalcohol; sodium oleate; sodium lauryl sulfate; magnesium lauryl sulfate;and the like. One or more lubricants, if present, typically constitutein total about 0.05% to about 10%, for example about 0.1% to about 5%,or about 0.2% to about 2%, by weight of the composition. Sodium stearylfumarate is a particularly useful lubricant.

Anti-adherents reduce sticking of a tablet formulation to equipmentsurfaces. Suitable anti-adherents include, either individually or incombination, talc, colloidal silicon dioxide, starch, DL-leucine, sodiumlauryl sulfate and metallic stearates. One or more anti-adherents, ifpresent, typically constitute in total about 0.05% to about 10%, forexample about 0.1% to about 7%, or about 0.2% to about 5%, by weight ofthe composition. Colloidal silicon dioxide is a particularly usefulanti-adherent.

Glidants improve flow properties and reduce static in a tabletingmixture. Suitable glidants include, either individually or incombination, colloidal silicon dioxide, starch, powdered cellulose,sodium lauryl sulfate, magnesium trisilicate and metallic stearates. Oneor more glidants, if present, typically constitute in total about 0.05%to about 10%, for example about 0.1% to about 7%, or about 0.2% to about5%, by weight of the composition, excluding glidant present in the soliddispersion. Colloidal silicon dioxide is a particularly useful glidant.

Other excipients such as buffering agents, stabilizers, antioxidants,antimicrobials, colorants, flavors and sweeteners are known in thepharmaceutical art and can be used in compositions of the presentinvention. Tablets can be uncoated or can comprise a core that iscoated, for example with a nonfunctional film or a release-modifying orenteric coating. Capsules can have hard or soft shells comprising, forexample, gelatin (in the form of hard gelatin capsules or soft elasticgelatin capsules), starch, carrageenan and/or HPMC, optionally togetherwith one or more plasticizers.

According to some embodiments of the present invention, a pharmaceuticalproduct is provided, the pharmaceutical product comprising (i) a firstcomposition comprising[3,4-Difluoro-2-(2-fluoro-4-iodoanilino)phenyl]{3-hydroxy-3-[(2S)-piperidin-2-yl]azetidin-1-yl}methanone(cobimetinib) or a pharmaceutically acceptable salt thereof, and (ii) asecond composition comprising4-(4-{[2-(4-chlorophenyl)-4,4-dimethylcyclohex-1-en-1-yl]methyl}piperazin-1-yl)-N-({3-nitro-4-[(tetrahydro-2H-pyran-4-ylmethyl)amino]phenyl}sulfonyl)-2-(1H-pyrrolo[2,3-b]pyridin-5-yloxy)benzamide(ABT-199) or a pharmaceutically acceptable salt thereof. As set forthabove, in some embodiments, the first composition further comprises apharmaceutically acceptable excipient. In some embodiments, the secondcomposition further comprises a pharmaceutically acceptable excipient.In some embodiments, the first composition and the second compositionare the same. In some embodiments, the first composition and the secondcomposition are different.

V. Indications

In some embodiments, the method of the present invention involves theadministration to a mammal, e.g., a human patient, in need of such atherapy a therapeutically effective amount of4-(4-{[2-(4-chlorophenyl)-4,4-dimethylcyclohex-1-en-1-yl]methyl}piperazin-1-yl)-N-({3-nitro-4-[(tetrahydro-2H-pyran-4-ylmethyl)amino]phenyl}sulfonyl)-2-(1H-pyrrolo[2,3-b]pyridin-5-yloxy)benzamide(venetoclax, or ABT-199/GDC-0199) or a pharmaceutically acceptable saltthereof and a therapeutically effective amount of[3,4-difluoro-2-(2-fluoro-4-iodoanilino)phenyl]{3-hydroxy-3-[(2S)-piperidin-2-yl]azetidin-1-yl}methanone(cobimetinib, or GDC-0973) or a pharmaceutically acceptable salt thereofto treat a disease during which is overexpressed one or more ofantiapoptotic Bcl-2 protein, antiapoptotic Bcl-X, protein andantiapoptotic Bcl-w protein.

In another embodiment, a composition of the invention is administered ina therapeutically effective amount to a subject in need thereof to treata disease of abnormal cell growth and/or dysregulated apoptosis.

Examples of such diseases include, but are not limited to, cancer,mesothelioma, bladder cancer, pancreatic cancer, skin cancer, cancer ofthe head or neck, cutaneous or intraocular melanoma, ovarian cancer,breast cancer, uterine cancer, carcinoma of the fallopian tubes,carcinoma of the endometrium, carcinoma of the cervix, carcinoma of thevagina, carcinoma of the vulva, bone cancer, colon cancer, rectalcancer, cancer of the anal region, stomach cancer, gastrointestinal(gastric, colorectal and/or duodenal) cancer, chronic lymphocyticleukemia, acute lymphocytic leukemia, esophageal cancer, cancer of thesmall intestine, cancer of the endocrine system, cancer of the thyroidgland, cancer of the parathyroid gland, cancer of the adrenal gland,sarcoma of soft tissue, cancer of the urethra, cancer of the penis,testicular cancer, hepatocellular (hepatic and/or biliary duct) cancer,primary or secondary central nervous system tumor, primary or secondarybrain tumor, Hodgkin's disease, chronic or acute leukemia, chronicmyeloid leukemia, lymphocytic lymphoma, lymphoblastic leukemia,follicular lymphoma, lymphoid malignancies of T-cell or B-cell origin,melanoma, multiple myeloma, oral cancer, non-small-cell lung cancer,prostate cancer, small-cell lung cancer, cancer of the kidney and/orureter, renal cell carcinoma, carcinoma of the renal pelvis, neoplasmsof the central nervous system, primary central nervous system lymphoma,non-Hodgkin's lymphoma, spinal axis tumors, brain stem glioma, pituitaryadenoma, adrenocortical cancer, gall bladder cancer, cancer of thespleen, cholangiocarcinoma, fibrosarcoma, neuroblastoma, retinoblastomaor a combination thereof.

In a more particular embodiment, the method of the present inventioninvolves the administration to a mammal, e.g., a human patient, in needof such a therapy a therapeutically effective amount of4-(4-{[2-(4-chlorophenyl)-4,4-dimethylcyclohex-1-en-1-yl]methyl}piperazin-1-yl)-N-({3-nitro-4-[(tetrahydro-2H-pyran-4-ylmethyl)amino]phenyl}sulfonyl)-2-(1H-pyrrolo[2,3-b]pyridin-5-yloxy)benzamide(venetoclax, or ABT-199/GDC-0199) or a pharmaceutically acceptable saltthereof and a therapeutically effective amount of[3,4-Difluoro-2-(2-fluoro-4-iodoanilino)phenyl]{3-hydroxy-3-[(2S)-piperidin-2-yl]azetidin-1-yl}methanone(cobimetinib, or GDC-0973) or a pharmaceutically acceptable salt thereofto treat to treat bladder cancer, brain cancer, breast cancer, bonemarrow cancer, cervical cancer, chronic lymphocytic leukemia, acutelymphocytic leukemia, colorectal cancer, esophageal cancer,hepatocellular cancer, lymphoblastic leukemia, follicular lymphoma,lymphoid malignancies of T-cell or B-cell origin, melanoma, myelogenousleukemia, myeloma, oral cancer, ovarian cancer, non-small-cell lungcancer, prostate cancer, small-cell lung cancer or spleen cancer.

In a more particular embodiment, the method of the present inventioninvolves the administration to a mammal, e.g., a human patient, in needof such a therapy a therapeutically effective amount of4-(4-{[2-(4-chlorophenyl)-4,4-dimethylcyclohex-1-en-1-yl]methyl}piperazin-1-yl)-N-({3-nitro-4-[(tetrahydro-2H-pyran-4-ylmethyl)amino]phenyl}sulfonyl)-2-(1H-pyrrolo[2,3-b]pyridin-5-yloxy)benzamide(venetoclax, or ABT-199/GDC-0199) or a pharmaceutically acceptable saltthereof and a therapeutically effective amount of[3,4-Difluoro-2-(2-fluoro-4-iodoanilino)phenyl]{3-hydroxy-3-[(2S)-piperidin-2-yl]azetidin-1-yl}methanone(cobimetinib, or GDC-0973) or a pharmaceutically acceptable salt thereofto treat to treat acute myeloid leukemia.

In a more particular embodiment, the method of the present inventioninvolves the administration to a mammal, e.g., a human patient, in needof such a therapy a therapeutically effective amount of4-(4-{[2-(4-chlorophenyl)-4,4-dimethylcyclohex-1-en-1-yl]methyl}piperazin-1-yl)-N-({3-nitro-4-[(tetrahydro-2H-pyran-4-ylmethyl)amino]phenyl}sulfonyl)-2-(1H-pyrrolo[2,3-b]pyridin-5-yloxy)(venetoclax, or ABT-199/GDC-0199) or a pharmaceutically acceptable saltthereof and a therapeutically effective amount of[3,4-Difluoro-2-(2-fluoro-4-iodoanilino)phenyl]{3-hydroxy-3-[(2S)-piperidin-2-yl]azetidin-1-yl}methanone(cobimetinib, or GDC-0973) or a pharmaceutically acceptable salt thereofto treat to treat multiple myeloma.

For example, a method for treating mesothelioma, bladder cancer,pancreatic cancer, skin cancer, cancer of the head or neck, cutaneous orintraocular melanoma, ovarian cancer, breast cancer, uterine cancer,carcinoma of the fallopian tubes, carcinoma of the endometrium,carcinoma of the cervix, carcinoma of the vagina, carcinoma of thevulva, bone cancer, colon cancer, rectal cancer, cancer of the analregion, stomach cancer, gastrointestinal (gastric, colorectal and/orduodenal) cancer, chronic lymphocytic leukemia, acute lymphocyticleukemia, esophageal cancer, cancer of the small intestine, cancer ofthe endocrine system, cancer of the thyroid gland, cancer of theparathyroid gland, cancer of the adrenal gland, sarcoma of soft tissue,cancer of the urethra, cancer of the penis, testicular cancer,hepatocellular (hepatic and/or biliary duct) cancer, primary orsecondary central nervous system tumor, primary or secondary braintumor, Hodgkin's disease, chronic or acute leukemia, chronic myeloidleukemia, lymphocytic lymphoma, lymphoblastic leukemia, follicularlymphoma, lymphoid malignancies of T-cell or B-cell origin, melanoma,multiple myeloma, oral cancer, non-small-cell lung cancer, prostatecancer, small-cell lung cancer, cancer of the kidney and/or ureter,renal cell carcinoma, carcinoma of the renal pelvis, neoplasms of thecentral nervous system, primary central nervous system lymphoma,non-Hodgkin's lymphoma, spinal axis tumors, brain stem glioma, pituitaryadenoma, adrenocortical cancer, gall bladder cancer, cancer of thespleen, cholangiocarcinoma, fibrosarcoma, neuroblastoma, retinoblastomaor a combination thereof in a subject comprises administering to thesubject therapeutically effective amounts of4-(4-{[2-(4-chlorophenyl)-4,4-dimethylcyclohex-1-en-1-yl]methyl}piperazin-1-yl)-N-({3-nitro-4-[(tetrahydro-2H-pyran-4-ylmethyl)amino]phenyl}sulfonyl)-2-(H-pyrrolo[2,3-b]pyridin-5-yloxy)benzamide(venetoclax, or ABT-199/GDC-0199) or a pharmaceutically acceptable saltthereof and a therapeutically effective amount of[3,4-Difluoro-2-(2-fluoro-4-iodoanilino)phenyl]{3-hydroxy-3-[(2S)-piperidin-2-yl]azetidin-1-yl}methanone(cobimetinib, or GDC-0973) or a pharmaceutically acceptable saltthereof.

In another embodiment, the method of the present invention involves theadministration to a mammal, e.g., a human patient, in need of such atherapy a therapeutically effective amount of44-{[2-(4-chlorophenyl)-4,4-dimethylcyclohex-1-en-1-yl]methyl}piperazin-1-yl)-N-({3-nitro-4-[(tetrahydro-2H-pyran-4-ylmethyl)amino]phenyl}sulfonyl)-2-(1H-pyrrolo[2,3-b]pyridin-5-yloxy)benzamide(venetoclax, or ABT-199/GDC-0199) or a pharmaceutically acceptable saltthereof and a therapeutically effective amount of[3,4-Difluoro-2-(2-fluoro-4-iodoanilino)phenyl]{3-hydroxy-3-[(2S)-piperidin-2-yl]azetidin-1-yl}methanone(cobimetinib, or GDC-0973) or a pharmaceutically acceptable salt thereofto treat an immune or autoimmune disorder. Such disorders includeacquired immunodeficiency disease syndrome (AIDS), autoimmunelymphoproliferative syndrome, hemolytic anemia, inflammatory diseases,thrombocytopenia, acute and chronic immune diseases associated withorgan transplantation, Addison's disease, allergic diseases, alopecia,alopecia areata, atheromatous disease/arteriosclerosis, atherosclerosis,arthritis (including osteoarthritis, juvenile chronic arthritis, septicarthritis, Lyme arthritis, psoriatic arthritis and reactive arthritis),autoimmune bullous disease, abetalipoprotemia, acquiredimmunodeficiency-related diseases, acute immune disease associated withorgan transplantation, acquired acrocyanosis, acute and chronicparasitic or infectious processes, acute pancreatitis, acute renalfailure, acute rheumatic fever, acute transverse myelitis,adenocarcinomas, aerial ectopic beats, adult (acute) respiratorydistress syndrome, AIDS dementia complex, alcoholic cirrhosis,alcohol-induced liver injury, alcohol-induced hepatitis, allergicconjunctivitis, allergic contact dermatitis, allergic rhinitis, allergyand asthma, allograft rejection, alpha-1-antitrypsin deficiency,Alzheimer's disease, amyotrophic lateral sclerosis, anemia, anginapectoris, ankylosing spondylitis-associated lung disease, anterior horncell degeneration, antibody mediated cytotoxicity, antiphospholipidsyndrome, anti-receptor hypersensitivity reactions, aortic andperipheral aneurysms, aortic dissection, arterial hypertension,arteriosclerosis, arteriovenous fistula, arthropathy, asthenia, asthma,ataxia, atopic allergy, atrial fibrillation (sustained or paroxysmal),atrial flutter, atrioventricular block, atrophic autoimmunehypothyroidism, autoimmune haemolytic anaemia, autoimmune hepatitis,type-1 autoimmune hepatitis (classical autoimmune or lupoid hepatitis),autoimmune mediated hypoglycemia, autoimmune neutropenia, autoimmunethrombocytopenia, autoimmune thyroid disease, B-cell lymphoma, bonegraft rejection, bone marrow transplant (BMT) rejection, bronchiolitisobliterans, bundle branch block, burns, cachexia, cardiac arrhythmias,cardiac stun syndrome, cardiac tumors, cardiomyopathy, cardiopulmonarybypass inflammation response, cartilage transplant rejection, cerebellarcortical degenerations, cerebellar disorders, chaotic or multifocalatrial tachycardia, chemotherapy-associated disorders, chlamydia,choleosatatis, chronic alcoholism, chronic active hepatitis, chronicfatigue syndrome, chronic immune disease associated with organtransplantation, chronic eosinophilic pneumonia, chronic inflammatorypathologies, chronic mucocutaneous candidiasis, chronic obstructivepulmonary disease (COPD), chronic salicylate intoxication, colorectalcommon varied immunodeficiency (common variable hypogammaglobulinemia),conjunctivitis, connective tissue disease-associated interstitial lungdisease, contact dermatitis. Coombs-positive hemolytic anemia, corpulmonale, Creutzfeldt-Jakob disease, cryptogenic autoimmune hepatitis,cryptogenic fibrosing alveolitis, culture-negative sepsis, cysticfibrosis, cytokine therapy-associated disorders. Crohn's disease,dementia pugilistica, demyelinating diseases, dengue hemorrhagic fever,dermatitis, dermatitis scleroderma, dermatologic conditions,dermatomyositis/polymyositis-associated lung disease, diabetes, diabeticarteriosclerotic disease, diabetes mellitus, diffuse Lewy body disease,dilated cardiomyopathy, dilated congestive cardiomyopathy, discoid lupuserythematosus, disorders of the basal ganglia, disseminatedintravascular coagulation, Down's Syndrome in middle age, drug-inducedinterstitial lung disease, drug-induced hepatitis, drug-induced movementdisorders induced by drugs which block CNS dopamine receptors, drugsensitivity, eczema, encephalomyelitis, endocarditis, endocrinopathy,enteropathic synovitis, epiglottitis, Epstein-Barr virus infection,erythromelalgia, extrapyramidal and cerebellar disorders, familialhematophagocytic lymphohistiocytosis, fetal thymus implant rejection,Friedreich's ataxia, functional peripheral arterial disorders, femaleinfertility, fibrosis, fibrotic lung disease, fungal sepsis, gasgangrene, gastric ulcer, giant cell arteritis, glomerular nephritis,glomerulonephritides, Goodpasture's syndrome, goitrous autoimmunehypothyroidism (Hashimoto's disease), gouty arthritis, graft rejectionof any organ or tissue, graft versus host disease, gram-negative sepsis,gram-positive sepsis, granulomas due to intracellular organisms, group Bstreptococci (GBS) infection, Graves' disease, hemosiderosis-associatedlung disease, hairy cell leukemia, Hallerrorden-Spatz disease,Hashimoto's thyroiditis, hay fever, heart transplant rejection,hemachromatosis, hematopoietic malignancies (leukemia and lymphoma),hemolytic anemia, hemolytic uremic syndrome/thrombolyticthrombocytopenic purpura, hemorrhage, Henoch-Schoenlein purpura,hepatitis A, hepatitis B, hepatitis C. HIV infection/HIV neuropathy,Hodgkin's disease, hypoparathyroidism, Huntington's chorea, hyperkineticmovement disorders, hypersensitivity reactions, hypersensitivitypneumonitis, hyperthyroidism, hypokinetic movement disorders,hypothalamic-pituitary-adrenal axis evaluation, idiopathic Addison'sdisease, idiopathic leucopenia, idiopathic pulmonary fibrosis,idiopathic thrombocytopenia, idiosyncratic liver disease, infantilespinal muscular atrophy, infectious diseases, inflammation of the aorta,inflammatory bowel disease, insulin dependent diabetes mellitus,interstitial pneumonitis, iridocyclitis/uveitis/optic neuritis,ischemia-reperfusion injury, ischemic stroke, juvenile pemicious anemia,juvenile rheumatoid arthritis, juvenile spinal muscular atrophy.Kaposi's sarcoma. Kawasaki's disease, kidney transplant rejection,legionella, leishmaniasis, leprosy, lesions of the corticospinal system,linear IgA disease, lipidema, liver transplant rejection, Lyme disease,lymphederma, lymphocytic infiltrative lung disease, malaria, maleinfertility idiopathic or NOS, malignant histiocytosis, malignantmelanoma, meningitis, meningococcemia, microscopic vasculitis of thekidneys, migraine headache, mitochondrial multisystem disorder, mixedconnective tissue disease, mixed connective tissue disease-associatedlung disease, monoclonal gammopathy, multiple myeloma, multiple systemsdegenerations (Mencel, Dejerine-Thomas, Shy-Drager and Machado-Joseph),myalgic encephalitis/Royal Free Disease, myasthenia gravis, microscopicvasculitis of the kidneys, Mycobacterium avium intracellulare,Mycobacterium tuberculosis, myelodyplastic syndrome, myocardialinfarction, myocardial ischemic disorders, nasopharyngeal carcinoma,neonatal chronic lung disease, nephritis, nephrosis, nephrotic syndrome,neurodegenerative diseases, neurogenic I muscular atrophies, neutropenicfever, non-alcoholic steatohepatitis, occlusion of the abdominal aortaand its branches, occlusive arterial disorders, organ transplantrejection, orchitis/epidydimitis, orchitis/vasectomy reversalprocedures, organomegaly, osteoarthrosis, osteoporosis, ovarian failure,pancreas transplant rejection, parasitic diseases, parathyroidtransplant rejection, Parkinson's disease, pelvic inflammatory disease,pemphigus vulgaris, pemphigus foliaceus, pemphigoid, perennial rhinitis,pericardial disease, peripheral atherlosclerotic disease, peripheralvascular disorders, peritonitis, pernicious anemia, phacogenic uveitis,Pneumocystis carinii pneumonia, pneumonia, POEMS syndrome(polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy,and skin changes syndrome), post-perfusion syndrome, post-pump syndrome,post-MI cardiotomy syndrome, postinfectious interstitial lung disease,premature ovarian failure, primary biliary cirrhosis, primary sclerosinghepatitis, primary myxoedema, primary pulmonary hypertension, primarysclerosing cholangitis, primary vasculitis, progressive supranuclearpalsy, psoriasis, psoriasis type 1, psoriasis type 2, psoriaticarthropathy, pulmonary hypertension secondary to connective tissuedisease, pulmonary manifestation of polyarteritis nodosa,post-inflammatory interstitial lung disease, radiation fibrosis,radiation therapy, Raynaud's phenomenon and disease, Raynoud's disease,Refsum's disease, regular narrow QRS tachycardia, Reiter's disease,renal disease NOS, renovascular hypertension, reperfusion injury,restrictive cardiomyopathy, rheumatoid arthritis-associated interstitiallung disease, rheumatoid spondylitis, sarcoidosis, Schmidt's syndrome,scleroderma, senile chorea, senile dementia of Lewy body type, sepsissyndrome, septic shock, seronegative arthropathies, shock, sickle cellanemia, Sjogren's disease-associated lung disease, Sjögren's syndrome,skin allograft rejection, skin changes syndrome, small bowel transplantrejection, sperm autoimmunity, multiple sclerosis (all subtypes), spinalataxia, spinocerebellar degenerations, spondyloarthropathy, sporadicpolyglandular deficiency type I, sporadic polyglandular deficiency typeII, Still's disease, streptococcal myositis, stroke, structural lesionsof the cerebellum, subacute sclerosing panencephalitis, sympatheticophthalmia, syncope, syphilis of the cardiovascular system, systemicanaphylaxis, systemic inflammatory response syndrome, systemic onsetjuvenile rheumatoid arthritis, systemic lupus erythematosus, systemiclupus erythematosus-associated lung disease, lupus nephritis, systemicsclerosis, systemic sclerosis-associated interstitial lung disease.T-cell or FAB ALL, Takaasu's disease/arteritis, telangiectasia, Th2-typeand Th1-type mediated diseases, thromboangitis obliterans,thrombocytopenia, thyroiditis, toxicity, toxic shock syndrome,transplants, trauma/hemorrhage, type-2 autoimmune hepatitis (anti-LKMantibody hepatitis), type B insulin resistance with acanthosisnigricans, type III hypersensitivity reactions, type IVhypersensitivity, ulcerative colitic arthropathy, ulcerative colitis,unstable angina, uremia, urosepsis, urticaria, uveitis, valvular heartdiseases, varicose veins, vasculitis, vasculitic diffuse lung disease,venous diseases, venous thrombosis, ventricular fibrillation, vitiligoacute liver disease, viral and fungal infections, vitalencephalitis/aseptic meningitis, vital-associated hemaphagocyticsyndrome, Wegener's granulomatosis, Wernicke-Korsakoff syndrome.Wilson's disease, xenograft rejection of any organ or tissue, yersiniaand salmonella-associated arthropathy and the like.

VI. Combination Dosing Regimens

The terms “orally deliverable”, “oral administration” and “orallyadministered” herein refer to administration to a subject per os (p.o.),that is, administration wherein the composition is immediatelyswallowed, for example with the aid of a suitable volume of water orother potable liquid. “Oral administration” is distinguished herein fromintraoral administration, e.g., sublingual or buccal administration ortopical administration to intraoral tissues such as periodontal tissues,that does not involve immediate swallowing of the composition.

The active ingredient form (e.g., parent compound or salt), thepolymeric carrier(s), surfactant(s) and other optional ingredientsshould be selected, and relative amounts of these components should beused, to provide a solid dispersion or dosage form having acceptablebioabsorption when administered orally. Such bioabsorption can beevidenced, for example, by the pharmacokinetic (PK) profile of the soliddispersion or dosage form, more particularly by the C_(max) or AUC, forexample AUC₀₋₂₄ or AUC_(0-∞) at a particular dose or over a range ofdoses. Illustratively, bioavailability can be expressed as a percentage,for example using the parameter F, which computes AUC for oral deliveryof a test composition as a percentage of AUC for intravenous (i.v.)delivery of the drug in a suitable solvent, taking into account anydifference between oral and i.v. doses.

Bioavailability can be determined by PK studies in humans or in anysuitable model species. For present purposes, a dog model is generallysuitable. In various illustrative embodiments, compositions of theinvention exhibit oral bioavailability of at least about 15%, at leastabout 20%, at least about 25% or at least about 30%, up to or exceedingabout 50%, in a dog model, when administered as a single dose of about2.5 to about 10 mg/kg to fasting or non-fasting animals.

Compositions embraced herein are useful for orally delivering a drug ora pharmaceutically acceptable salt thereof to a subject. Accordingly, amethod of the invention for delivering such a drug to a subjectcomprises orally administering a composition as described above.

The subject can be human or non-human (e.g., a farm, zoo, work orcompanion animal, or a laboratory animal used as a model) but in animportant embodiment the subject is a human patient in need of the drug,for example to treat a disease characterized by apoptotic dysfunctionand/or overexpression of an anti-apoptotic Bcl-2 family protein. A humansubject can be male or female and of any age. The patient is typicallyan adult, but a method of the invention can be useful to treat achildhood cancer such as leukemia, for example acute lymphocyticleukemia, in a pediatric patient.

The composition is normally administered in an amount providing atherapeutically effective daily dose of the drug. The term “daily dose”herein means the amount of drug administered per day, regardless of thefrequency of administration. For example, if the subject receives a unitdose of 150 mg twice daily, the daily dose is 300 mg. Use of the term“daily dose” will be understood not to imply that the specified dosageamount is necessarily administered once daily. However, in a particularembodiment the dosing frequency is once daily (q.d.), and the daily doseand unit dose are in this embodiment the same thing.

What constitutes a therapeutically effective dose depends on theparticular compound, the subject (including species and body weight ofthe subject), the disease (e.g., the particular type of cancer) to betreated, the stage and/or severity of the disease, the individualsubject's tolerance of the compound, whether the compound isadministered in monotherapy or in combination with one or more otherdrugs, e.g., other chemotherapeutics for treatment of cancer, and otherfactors. Thus the daily dose can vary within wide margins, for examplefrom about 10 to about 1,000 mg. Greater or lesser daily doses can beappropriate in specific situations. It will be understood thatrecitation herein of a “therapeutically effective” dose herein does notnecessarily require that the drug be therapeutically effective if only asingle such dose is administered; typically therapeutic efficacy dependson the composition being administered repeatedly according to a regimeninvolving appropriate frequency and duration of administration. It isstrongly preferred that, while the daily dose selected is sufficient toprovide benefit in terms of treating the cancer, it should not besufficient to provoke an adverse side-effect to an unacceptable orintolerable degree. A suitable therapeutically effective dose can beselected by the physician of ordinary skill without undueexperimentation based on the disclosure herein and on art cited herein,taking into account factors such as those mentioned above. The physicianmay, for example, start a cancer patient on a course of therapy with arelatively low daily dose and titrate the dose upwards over a period ofdays or weeks, to reduce risk of adverse side-effects.

Illustratively, suitable doses are generally about 25 to about 1,000mg/day, more typically about 50 to about 500 mg/day or about 200 toabout 400 mg/day, for example about 50, about 100, about 150, about 200,about 250, about 300, about 350, about 400, about 450 or about 500mg/day, administered at an average dosage interval of about 3 hours toabout 7 days, for example about 8 hours to about 3 days, or about 12hours to about 2 days. In most cases a once-daily (q.d.) administrationregimen is suitable.

An “average dosage interval” herein is defined as a span of time, forexample one day or one week, divided by the number of unit dosesadministered over that span of time. For example, where a drug isadministered three times a day, around 8 am, around noon and around 6pm, the average dosage interval is 8 hours (a 24-hour time span dividedby 3). If the drug is formulated as a discrete dosage form such as atablet or capsule, a plurality (e.g., 2 to about 10) of dosage formsadministered at one time is considered a unit dose for the purpose ofdefining the average dosage interval.

Where the composition is in the form of a capsule, one to a smallplurality of capsules can be swallowed whole, typically with the aid ofwater or other imbibable liquid to help the swallowing process. Suitablecapsule shell materials include, without limitation, gelatin (in theform of hard gelatin capsules or soft elastic gelatin capsules), starch,carrageenan and HPMC.

Administration can be with or without food, i.e., in anon-fasting orfasting condition. It is generally preferred to administer the presentcompositions to a non-fasting patient.

VII. Additional Combinations

The combination therapy of the present invention may be suitable for usein with other chemotherapeutics or with ionizing radiation. Combinationtherapies illustratively include administration of a combination therapyof the present invention concomitantly with one or more of bortezomib,carboplatin, cisplatin, cyclophosphamide, dacarbazine, dexamethasone,docetaxel, doxorubicin, etoposide, fludarabine, irinotecan, paclitaxel,rapamycin, rituximab, vincristine and the like, for example with apolytherapy such as CHOP(cyclophosphamide+doxorubicin+vincristine+prednisone), RCVP(rituximab+cyclophosphamide+vincristine+prednisone), R-CHOP(rituximab+CHOP) or DA-EPOCH-R (dose-adjusted etoposide, prednisone,vincristine, cyclophosphamide, doxorubicin and rituximab).

Additional examples of one or more therapeutic agents include, but arenot limited to, alkylating agents, angiogenesis inhibitors, antibodies,antimetabolites, antimitotics, antiproliferatives, antivirals, aurorakinase inhibitors, other apoptosis inducing agents (for example, Bcl-xL,Bcl-w and Bfl-1 inhibitors), activators of a death receptor pathway,Bcr-Abl kinase inhibitors, BiTE (bi-specific T-cell engager) antibodies,antibody-drug conjugates, biological response modifiers,cyclin-dependent kinase (CDK) inhibitors, cell cycle inhibitors,cyclooxygenase-2 (COX-2) inhibitors, dual variable domain bindingproteins (DVDs), human epidermal growth factor receptor 2 (ErbB2 orHER/2neu) receptor inhibitors, growth factor inhibitors, heat shockprotein (HSP)-90 inhibitors, histone deacetylase (HDAC) inhibitors,hormonal therapies, immunologicals, inhibitors of apoptosis proteins(IAPs), intercalating antibiotics, kinase inhibitors, kinesininhibitors. JAK2 inhibitors, mammalian target of rapamycin (mTOR)inhibitors, microRNAs, mitogen-activated extracellular signal-regulatedkinase (MEK) inhibitors, multivalent binding proteins, non-steroidalanti-inflammatory drugs (NSAIDs), poly-ADP (adenosinediphosphate)-ribose polymerase (PARP) inhibitors, platinumchemotherapeutics, polo-like kinase (Plk) inhibitors, phosphoinositide-3kinase (PI3K) inhibitors, proteasome inhibitors, purine analogs,pyrimidine analogs, receptor tyrosine kinase inhibitors, retinoids,deltoids, plant alkaloids, small inhibitory ribonucleic acids (siRNAs),topoisomerase inhibitors, ubiquitin ligase inhibitors, and the like.

BiTE antibodies are bi-specific antibodies that direct T-cells to attackcancer cells by simultaneously binding the two cells. The T-cell thenattacks the target cancer cell. Examples of BiTE antibodies include, butare not limited to, adecatumumab (Micromet MT201), blinatumomab(Micromet MT103) and the like. Without being limited by theory, one ofthe mechanisms by which T-cells elicit apoptosis of the target cancercell is by exocytosis of cytolytic granule components, which includeperforin and granzyme B. In this regard, Bcl-2 has been shown toattenuate the induction of apoptosis by both perform and granzyme B.These data suggest that inhibition of Bcl-2 could enhance the cytotoxiceffects elicited by T-cells when targeted to cancer cells (Sutton et al.(1997) J. Immunol. 158:5783-5790).

siRNAs are molecules having endogenous RNA bases or chemically modifiednucleotides. The modifications do not abolish cellular activity, butrather impart increased stability and/or increased cellular potency.Examples of chemical modifications include phosphorothioate groups,2′-deoxynucleotide, 2′-OCH₃-containing ribonucleotides,2′-F-ribonucleotides, 2′-methoxyethyl ribonucleotides, combinationsthereof and the like. The siRNA can have varying lengths (e.g., 10-200bps) and structures (e.g., hairpins, single/double strands, bulges,nicks/gaps, mismatches) and are processed in cells to provide activegene silencing. A double-stranded siRNA (dsRNA) can have the same numberof nucleotides on each strand (blunt ends) or asymmetric ends(overhangs). The overhang of 1-2 nucleotides can be present on the senseand/or the antisense strand, as well as present on the 5′- and/or the3′-ends of a given strand. For example, siRNAs targeting Mcl-1 have beenshown to enhance the activity of ABT-263 or ABT-737 in various tumorcell lines (Tse et al. (2008) Cancer Res. 68:3421-3428 and referencestherein).

Multivalent binding proteins are binding proteins comprising two or moreantigen binding sites. Multivalent binding proteins are engineered tohave the three or more antigen binding sites and are generally notnaturally occurring antibodies. The term “multispecific binding protein”means a binding protein capable of binding two or more related orunrelated targets. Dual variable domain (DVD) binding proteins aretetravalent or multivalent binding proteins binding proteins comprisingtwo or more antigen binding sites. Such DVDs may be monospecific (i.e.,capable of binding one antigen) or multispecific (i.e., capable ofbinding two or more antigens). DVD binding proteins comprising twoheavy-chain DVD polypeptides and two light-chain DVD polypeptides arereferred to as DVD g's. Each half of a DVD Ig comprises a heavy-chainDVD polypeptide, a light-chain DVD polypeptide, and two antigen bindingsites. Each binding site comprises a heavy-chain variable domain and alight-chain variable domain with a total of 6 CDRs involved in antigenbinding per antigen binding site.

Alkylating agents include altretamine, AMD-473, AP-5280, apaziquone,bendamustine, brostallicin, busulfan, carboquone, carmustine (BCNU),chlorambucil. Cloretazine™ (laromustine, VNP 40101M), cyclophosphamide,dacarbazine, estramustine, fotemustine, glufosfamide, ifosfamide,KW-2170, lomustine (CCNU), mafosfamide, melphalan, mitobronitol,mitolactol, nimustine, nitrogen mustard N-oxide, ranimustine,temozolomide, thiotepa, treosulfan, trofosfamide and the like.

Angiogenesis inhibitors include epidermal growth factor receptor (EGFR)inhibitors, endothelial-specific receptor tyrosine kinase (Tie-2)inhibitors, insulin growth factor-2 receptor (IGFR-2) inhibitors, matrixmetalloproteinase-2 (MMP-2) inhibitors, matrix metalloproteinase-9(MMP-9) inhibitors, platelet-derived growth factor receptor (PDGFR)inhibitors, thrombospondin analogs, vascular endothelial growth factorreceptor tyrosine kinase (VEGFR) inhibitors and the like.

Antimetabolites include Alimta™ (pemetrexed disodium, LY231514, MTA),5-azacitidine, Xeloda™, (capecitabine), carmofur, Leustat™ (cladribine),clofarabine, cytarabine, cytarabine ocfosfate, cytosine arabinoside,decitabine, deferoxamine, doxifluridine, eflornithine, EICAR(5-ethynyl-1-β-D-ribofuranosylimidazole-4-carboxamide), enocitabine,ethenylcytidine, fludarabine, 5-fluorouracil (5-FU) alone or incombination with leucovorin, Gemzar™ (gemcitabine), hydroxyurea,Alkeran™ (melphalan), mercaptopurine, 6-mercaptopurine riboside,methotrexate, mycophenolic acid, nelarabine, nolatrexed, ocfosfate,pelitrexol, pentostatin, raltitrexed, ribavirin, S-1, triapine,trimetrexate, TS-1, tiazofurin, tegafur, vidarabine, UFT and the like.

Antivirals include ritonavir, hydroxychloroquine and the like.

Aurora kinase inhibitors include ABT-348, AZD-1152, MLN-8054, VX-680,aurora A-specific kinase inhibitors, aurora B-specific kinaseinhibitors, pan-aurora kinase inhibitors and the like.

Bcl-2 family protein inhibitors other than compounds of Formula I hereininclude AT-101 ((−)gossypol), Genasense™ Bcl-2-targeting antisenseoligonucleotide (G3139 or oblimersen), IPI-194, IPI-565, ABT-737,ABT-263, GX-070 (obatoclax) and the like.

Bcr-Abl kinase inhibitors include dasatinib (BMS-354825), Gleevec™(imatinib) and the like.

CDK inhibitors include AZD-5438, BMI-1040, BMS-387032, CVT-2584,flavopyridol, GPC-286199, MCS-5A, PD0332991, PHA-690509, seliciclib(CYC-202 or R-roscovitine), ZK-304709 and the like.

COX-2 inhibitors include ABT-963, Arcoxia™ (etoricoxib). Bextram™(valdecoxib), BMS-347070, Celebrex™ (celecoxib), COX-189 (lumiracoxib),CT-3, Deramaxx™ (deracoxib), JTE-522,4-methyl-2-(3,4-dimethylphenyl)-1-(4-sulfamoylphenyl)-1H-pyrrole, MK-663(etoricoxib), NS-398, parecoxib, RS-57067, SC-58125, SD-8381, SVT-2016,5-2474, T-614, Vioxx™ (rofecoxib) and the like.

EGFR inhibitors include ABX-EGF, anti-EGFR immunoliposomes, EGF-vaccine,EMD-7200, Erbitux™ (cetuximab), HR3, IgA antibodies, Iressa™(gefitinib), Tarcevar™ (erlotinib or OSI-774), TP-38, EGFR fusionprotein, Tykerb™ (lapatinib) and the like.

ErbB2 receptor inhibitors include CP-724714, CI-1033 (canertinib),Herceptin™ (trastuzumab), Tykerb™ (lapatinib), Omnitarg™ (2C4,petuzumab), TAK-165, GW-572016 (ionafamib), GW-282974, EKB-569, PI-166,dHER2 (HER2 vaccine), APC-8024 (HER2 vaccine), anti-HER/2neu bispecificantibody. B7.her2IgG3, AS HER2 trifunctional bispecific antibodies, mABAR-209, mAB 2B-1 and the like.

Histone deacetylase inhibitors include depsipeptide, LAQ-824, MS-275,trapoxin, suberoylanilide hydroxamic acid (SAHA), TSA, valproic acid andthe like.

HSP-90 inhibitors include 17AAG, CNF-101, CNF-1010, CNF-2024, 17-DMAG,geldanamycin, IPI-504, KOS-953, Mycograb™ (human recombinant antibody toHSP-90), nab-17AAG, NCS-683664, PU24FCl, PU-3, radicicol, SNX-2112,STA-9090, VER-49009 and the like.

Inhibitors of apoptosis proteins include HGS-1029, GDC-0145, GDC-0152,LCL-161, LBW-242 and the like.

Antibody-drug conjugates include anti-CD22-MC-MMAF, anti-CD22-MC-MMAE,anti-CD22-MCC-DM1, CR-011-vcMMAE, PSMA-ADC, MEDI-547, SGN-19A SGN-35,SGN-75 and the like.

Activators of death receptor pathway include TRAIL and antibodies orother agents that target TRAIL or death receptors (e.g., DR4 and DR5)such as apomab, conatumumab, ETR2-ST01, GDC0145 (lexatumumab), HGS-1029,LBY-135, PRO-1762, trastuzumab and the like.

Kinesin inhibitors include Eg5 inhibitors such as AZD-4877 and ARRY-520CENPE inhibitors such as GSK-923295A, and the like.

JAK2 inhibitors include CEP-701 (lesaurtinib), XL019, INCB-018424 andthe like.

MEK inhibitors include ARRY-142886, ARRY-438162, PD-325901, PD-98059 andthe like.

mTOR inhibitors include AP-23573, CCI-779, everolimus, RAD-001,rapamycin, temsirolimus, ATP-competitive TORC1/TORC2 inhibitors,including PI-103, PP242, PP30 and Torin 1, and the like.

Non-steroidal anti-inflammatory drugs include Amigesic™ (salsalate),Dolobid™ (diflunisal), Motrin™ (ibuprofen), Orudis™ (ketoprofen),Relafen™ (nabumetone), Feldene™ (piroxicam), ibuprofen cream. Aleve™ andNaprosyn™ (naproxen), Voltaren™ (diclofenac), Indocin™ (indomethacin),Clinoril™ (sulindac), Tolectin™ (tolmetin), Lodine™ (etodolac), Toradol™(ketorolac), Daypro™ (oxaprozin) and the like.

PDGFR inhibitors include CP-673451, CP-868596 and the like.

Platinum chemotherapeutics include cisplatin, Eloxatin™ (oxaliplatin),eptaplatin, lobaplatin, nedaplatin, Paraplatin™ (carboplatin),picoplatin, satraplatin and the like.

Polo-like kinase inhibitors include B1-2536 and the like.

Phosphoinositide-3 kinase inhibitors include wortmannin, LY-294002,XL-147. CAL-120, ONC-21, AEZS-127, ETP-45658, PX-866, GDC-0941, BGT226,BEZ235, XL765 and the like.

Thrombospondin analogs include ABT-510, ABT-567, ABT-898, TSP-1 and thelike.

VEGFR inhibitors include Avastin™ (bevacizumab), ABT-869, AEE-788,Angiozyme™ (a ribozyme that inhibits angiogenesis (RibozymePharmaceuticals (Boulder, Colo.) and Chiron (Emeryville. Calif.)),axitinib (AG-13736), AZD-2171. CP-547632, IM-862, Macugen™ (pegaptanib),Nexavar™ (sorafenib, BAY43-9006), pazopanib (GW-786034), vatalanib(PTK-787 or ZK-222584), Sutent™ (sunitinib or SU-11248), VEGF trap,Zactim™ (vandetanib or ZD-6474) and the like.

Antibiotics include intercalating antibiotics such as aclarubicin,actinomycin D, amrubicin, annamycin, Adriamycin™ (doxorubicin),Blenoxane™ (bleomycin), daunorubicin, Caelyx™ and Myocet™ (liposomaldoxorubicin), elsamitrucin, epirubicin, glarubicin, idarubicin,mitomycin C, nemorubicin, neocarzinostatin, peplomycin, pirarubicin,rebeccamycin, stimalamer, streptozocin, Valstar™ (valrubicin),zinostatin and the like.

Topoisomerase inhibitors include aclarubicin, 9-aminocamptothecin,amonafide, amsacrine, becatecarin, belotecan, BN-80915, Camptosar™(irinotecan hydrochloride), camptothecin, Cardioxane™ (dexrazoxane),diflomotecan, edotecarin, Ellence™ and Pharmorubicin™ (epirubicin),etoposide, exatecan, 10-hydroxycamptothecin, gimatecan, lurtotecan,mitoxantrone, orathecin, pirarbucin, pixantrone, rubitecan, sobuzoxane,SN-38, tafluposide, topotecan and the like.

Antibodies include Avastin™ (bevacizumab), CD40-specific antibodies,chTNT-1/B, denosumab, Erbitux™ (cetuximab), Humax-CD4™ (zanolimumab),IGF1R-specific antibodies, lintuzumab, Panorex™ (edrecolomab), Rencarex™(WX G250), Rituxan™ (rituximab), ticilimumab, trastuzumab, CD20antibodies types I and 11 and the like.

Hormonal therapies include Arimidex™ (anastrozole), Aromasin™(exemestane), arzoxifene, Casodex™ (bicalutamide), Cetrotide™(cetrorelix), degarelix, deslorelin, Desopan™ (trilostane),dexamethasone, Drogenil™ (flutamide), Evista™ (raloxifene), Afema™(fadrozole), Fareston™ (toremifene), Faslodex™ (fulvestrant), Femara™(letrozole), formestane, glucocorticoids. Hectorol™ (doxercalciferol),Renagel™ (sevelamer carbonate), lasofoxifene, leuprolide acetate,Megace™ (megestrol), Mifeprex™ (mifepristone), Nilandron™ (nilutamide),tamoxifen including Nolvadex™ (tamoxifen citrate), Plenaxis™ (abarelix),prednisone, Propecia™ (finasteride), rilostane, Suprefact™ (buserelin),luteinizing hormone releasing hormone (LHRH) including Trelstar™(triptorelin), histrelin including Vantas™ (histrelin implant),Modrastane™ (trilostane), Zoladex™ (goserelin) and the like.

Deltoids and retinoids include seocalcitol (EB1089 or CB1093),lexacalcitol (KH1060), fenretinide, Panretin™ (alitretinoin), tretinoinincluding Atragen™ (liposomal tretinoin), Targretin™ (bexarotene),LGD-1550 and the like.

PARP inhibitors include ABT-888, olaparib, KU-59436, AZD-2281,AG-014699, BSI-201. BGP-15, INO-1001, ONO-2231 and the like.

Plant alkaloids include vincristine, vinblastine, vindesine, vinorelbineand the like.

Proteasome inhibitors include Velcade™ (bortezomib), MG132, NPI-0052,PR-171 and the like.

Examples of immunologicals include interferons and otherimmune-enhancing agents. Interferons include interferon alpha,interferon alpha-2a, interferon alpha-2b, interferon beta, interferongamma-1a. Actimmune™ (interferon gamma-1b), interferon gamma-n1,combinations thereof and the like. Other agents include Alfaferone(IFN-α), BAM-002 (oxidized glutathione), Beromun™ (tasonermin), Bexxar™(tositumomab), Campath™ (alemtuzumab), CTLA4 (cytotoxic lymphocyteantigen 4), dacarbazine, denileukin, epratuzumab, Granocyte™(lenograstim), lentinan, leukocyte alpha interferon, imiquimod, MDX-010(anti-CTLA-4), melanoma vaccine, mitumomab, molgramostim, Mylotarg™(gemtuzumab ozogamicin), Neupogen™ (filgrastim), OncoVAC-CL, Ovarex™(oregovomab), pemtumomab (Y-muHMFG1), Provenge™ (sipuleucel-T),sargaramostim, sizofiran, teceleukin Theracys™ (BCG or BacillusCalmette-Guerin), ubenimex, Virulizin™ (immunotherapeutic, LorusPharmaceuticals), Z-100 (Specific Substance of Maruyama or SSM), WF-10(tetrachlorodecaoxide or TCDO), Proleukin™ (aldesleukin), Zadaxin™(thymalfasin), Zenapax™ (daclizumab), Zevalin™ (90Y-ibritumomabtiuxetan) and the like.

Biological response modifiers are agents that modify defense mechanismsof living organisms or biological responses, such as survival, growth ordifferentiation of tissue cells to direct them to have anti-tumoractivity, and include krestin, lentinan, sizofiran, picibanil,PF-3512676 (CpG-8954), ubenimex and the like.

Pyrimidine analogs include cytarabine (cytosine arabinoside, ara C orarabinoside C), doxifluridine, Fludara™ (fludarabine), 5-FU(5-fluorouracil), floxuridine, Gemzar™ (gemcitabine), Tomudex™(raltitrexed), triacetluridine. Troxatvl™ (troxacitabine) and the like.

Purine analogs include Lanvis™ (thioguanine), Purinethol™(mercaptopurine) and the like.

Antimitotic agents include batabulin, epothilone D (KOS-862),N-(2-((4-hydroxy-phenyl)amino)pyridin-3-yl)-4-methoxybenzenesulfonamide,ixabepilone (BMS-247550), paclitaxel, Taxotere™ (docetaxel), larotaxel(PNU-100940, RPR-109881 or XRP-9881), patupilone, vinflunine, ZK-EPO(synthetic epothilone) and the like.

Ubiquitin ligase inhibitors include MDM2 inhibitors such as nutlins,NEDD8 inhibitors such as MLN4924, and the like.

The combination therapy of this present invention may also be used asradiosensitizers that enhance the efficacy of radiotherapy. Examples ofradiotherapy include, but are not limited to, external beam radiotherapy(XBRT), teletherapy, brachytherapy, sealed-source radiotherapy,unsealed-source radiotherapy and the like.

Additionally or alternatively, the combination therapy of the presentinvention can be administered in combination therapy with one or moreantitumor or chemotherapeutic agents selected from Abraxane™ (ABI-007),ABT-100 (famesyl transferase inhibitor), Advexin™ (Ad5CMV-p53 vaccine orcontusugene ladenovec), Altocor™ or Mevacor™ (lovastatin), Ampligen™(poly(I)-poly(C12U), a synthetic RNA), Aptosyn™ (exisulind), Aredia™(pamidronic acid), arglabin, L-asparaginase, atamestane(1-methyl-3,17-dione-androsta-1,4-diene), Avage™ (tazarotene), AVE-8062(combretastatin derivative), BEC2 (mitumomab), cachectin or cachexin(tumor necrosis factor), Canvaxin™ (melanoma vaccine), CeaVac™ (cancervaccine), Celeuk™ (celmoleukin), histamine including Ceplene™ (histaminedihydrochloride), Cervarix™ (AS04 adjuvant-adsorbed human papillomavirus (HPV) vaccine), CHOP (Cytoxan™ (cyclophosphamide)+Adriamycin™(doxorubicin)+Oncovin™ (vincristine)+prednisone), combretastatin A4P,Cypat™ (cyproterone), DAB(389)EGF (catalytic and translocation domainsof diphtheria toxin fused via a His-Ala linker to human epidermal growthfactor), dacarbazine, dactinomycin, Dimericine™ (T4N5 liposome lotion),5,6-dimethylxanthenone-4-acetic acid (DMXAA), discodermolide, DX-8951f(exatecan mesylate), eniluracil (ethynyluracil), squalamine includingEvizon™ (squalamine lactate), enzastaurin, EPO-906 (epothilone B),Gardasil™ (quadrivalent human papilloma virus (Types 6, 11, 16, 18)recombinant vaccine), Gastrimmune™, Genasense™ (oblimersen), GMK(ganglioside conjugate vaccine), GVAX™ (prostate cancer vaccine),halofuginone, histerelin, hydroxycarbamide, ibandronic acid, IGN-101,IL-13-PE38, IL-13-PE38QQR (cintredekin besudotox), IL-13-pseudomonasexotoxin, interferon-α, interferon-γ, Junovan™ and Mepact™(mifamurtide), lonafamib, 5,10-methylenetetrahydrofolate, miltefosine(hexadecylphosphocholine), Neovastat™ (AE-941), Neutrexin™ (trimetrexateglucuronate), Nipent™ (pentostatin), Onconase™ (ranpimase, aribonuclease enzyme), Oncophage™ (vitespen, melanoma vaccine treatment),OncoVAX™ (IL-2 vaccine), Orathecin™ (rubitecan), Osidem™ (antibody-basedcell drug), Ovarex™ MAb (murine monoclonal antibody), paclitaxelalbumin-stabilized nanoparticle, paclitaxel, Pandimex™ (aglyconesaponins from ginseng comprising 20(S)-protopanaxadiol (aPPD) and20(S)-protopanaxatriol (aPPT)), panitumumab, Panvac™-VF (investigationalcancer vaccine), pegaspargase, peginterferon alfa (PEG interferon A),phenoxodiol, procarbazine, rebimastat, Removab™ (catumaxomab), Revlimid™(lenalidomide), RSR13 (efaproxiral), Somatuline™ LA (lanreotide),Soriatane™ (acitretin), staurosporine (Streptomyces staurospores),talabostat (PT100), Targretin™ (bexarotene), Taxoprexin™(docosahexaenoic acid (DHA)+paclitaxel), Telcytar™ (canfosfamide,TLK-286), Temodar™ (temozolomide), tesmilifene, tetrandrine,thalidomide, Theratope™ (STn-KLH vaccine), Thymitaq™ (nolatrexeddihydrochloride), TNFerade™ (adenovector: DNA carrier containing thegene for tumor necrosis factor-α), Tracleer™ or Zavesca™ (bosentan),TransMID-107R™ (KSB-311, diphtheria toxins), tretinoin (retin-A),Trisenox™ (arsenic trioxide), Ukrain™ (derivative of alkaloids from thegreater celandine plant), Virulizin™, Vitaxin™ (anti-αvβ3 antibody),Xcytrin™ (motexafin gadolinium), Xinlay™ (atrasentan), Xyotax™(paclitaxel poliglumex) Yondelis™ (trabectedin), ZD-6126(N-acetylcolchinol-O-phosphate), Zinecard™ (dexrazoxane), zoledronicacid, zorubicin and the like.

Other objects and features will be in part apparent and in part pointedout hereinafter.

EXAMPLES

The following non-limiting examples are provided to further illustratethe present invention.

The activity of4-(4-{[2-(4-chlorophenyl)-4,4-dimethylcyclohex-1-en-1-yl]methyl}piperazin-1-yl)-N-({3-nitro-4-[(tetrahydro-2H-pyran-4-ylmethyl)amino]phenyl}sulfonyl)-2-(1H-pyrrolo[2,3-b]pyridin-5-yloxy)benzamide(ABT-199, or venetoclax) and[3,4-Difluoro-2-(2-fluoro-4-iodoanilino)phenyl]{3-hydroxy-3-[(2S)-piperidin-2-yl]azetidin-1-yl}methanone(cobimetinib) was examined in a panel of myeloid leukemia cell lineswith diverse genetic alterations. The IC₅₀ values of cobimetinib rangedfrom <0.01 μM to >1 μM after 72 hours of drug treatment but did notcorrelate with the basal level of p-ERK1/2. (FIG. 1A). In 7 out of 11cell lines, combination of the agents elicited synergistic growthinhibition. Notably synergism of venetoclax with cobimetinib wasobserved in venetoclax-resistant cell lines (MOLM14, OCI-AML3, NB4 andTHP1). (FIGS. 1B through 1L). In a long-term culture of primary AMLblasts, the combination of venetoclax and cobimetinib predominantlysuppressed cell proliferation and induced distinct apoptotic cell deathin a subset of AML samples. The clonogenic potential of myeloidprogenitors was significantly suppressed by the combination, while thenormal progenitor function was minimally affected. (FIGS. 2A, 2B, and2C).

Ongoing analysis of pharmacodynamic markers include transcriptomeassessment by RNA sequencing, functional proteomics by reverse phaseprotein array (RPPA), and quantification of Bcl-2:BIM and MCL-1:BIMcomplexes using the electrochemiluminescent ELISA assay (Meso ScaleDiscovery, MSD-ELISA). RPPA is a high-throughput technology thatperforms protein assays on thousands of samples simultaneously. Thisprotein array platform measures levels of protein expression, as well asprotein modifications such as phosphorylation. RPPA data demonstrateddifferentially expressed proteins in sensitive and resistant cell linesto cobimetinib or venetoclax as single agents or in combination. See thefollowing Tables 1, 2, and 3.

TABLE 1 COBIMETINIB: SENSITIVE V. RESISTANT Protein Pval Mean. Res Mean.Sens Bax 8.64E−15 1.010 1.307 Bim 2.87E−13 0.893 1.175 ERK 1/2(T202/Y204) 1.47E−09 1.073 1.988 FLT3 (Y589/591) 1.71E−12 0.948 1.256p16INK4a 6.56E−23 2.220 1.184 p38MAP (T180/Y182) 0.00174 0.983 1.275 p534.87E−10 0.939 1.373 PTEN 3.92E−18 1.013 1.361 PTEN (S380) 0.0003  1.0491.335 RSK3 (T356/S360) 1.09E−15 0.859 1.495 S6 (S235/236) 0.00012 0.7481.174

TABLE 2 VENETOCLAX: SENSITIVE V. RESISTANT Protein Pval Mean. Res Mean.Sens bRaf (T401) 5.44E−10 1.263 0.927 Bax 1.48E−15 0.958 1.227 Bcl-21.28E−19 0.817 1.081 Bim 3.41E−20 1.143 0.811 p16INK4a 3.09E−06 1.9891.593 PTEN 2.39E−20 0.704 1.495 PTEN (S380) 1.88E−09 0.839 1.369 S6(S240/244) 8.51E−05 1.918 1.571

TABLE 3 COMBINATION: SENSITIVE V. RESISTANT Protein Pval Mean. Res Mean.Sens Bad 1.65E−07 1.232 0.923 Bad (S112) 3.26E−07 1.272 0.938 Bcl22.12E−22 0.373 1.051 Caspase 3 2.66E−16 1.526 0.998 Caspase 3 CleavedD175 0.000127321 0.938 1.359 Caspase 7 Cleaved D198 5.53E−09 0.590 1.771Caspase 8 Cleaved D391 2.19E−05 0.804 1.409 eIF2a (S51) 2.26E−08 1.3930.850 ERK 1/2 9.81E−13 0.802 1.098 p16INK4a 1.03E−14 3.786 1.326 p70 p85S6 (S371/S394) 1.84E−05 0.726 1.054 PARP Cleaved D214 9.37E−07 0.6801.477 PTEN 2.39E−11 0.508 1.178 PTEN (S380) 9.64E−05 0.661 1.109 RSK3(T356/S360) 8.80E−06 0.789 1.130

Representative proteins that are differentially expressed in sensitiveand resistant cell lines to the combination. (FIGS. 3A, 3B, 3C, and 3D).The preliminary MSD data revealed that Bcl-2:BIM complex was disruptedby venetoclax in most cell lines and accumulated following cobimetinibtreatment in OCI-AML3 cells, which may be due to the disruption ofMCL-1:BIM complex by inhibition of MEK releasing BIM to bind with Bcl-2.(FIG. 3E).

We next investigated signaling patterns and Bcl-2 family proteinexpression in AML stem/progenitor cells using a 34-antibody panel andtime-of-flight mass cytometry (CyTOF). CyTOF is a variation of flowcytometry in which antibodies are labeled with heavy metal ion tagsrather than fluorochromes. Readout is by time-of-flight massspectrometry. This allows for the combination of many more antibodyspecificities in single samples, without significant spillover betweenchannels. In AML 4295468. Bcl-2 was expressed in leukemia blasts, withenrichment in a progenitor AML population phenotypically defined asCD45dimCD34+CD38+CD123+CD33+. (FIG. 4A). The high expression level ofBcl-2 and low expression of MCL-1 and BCL-XL may account for sensitivityto venetoclax in AML 4295468. A venetoclax-resistant AML (4366894)showed low expression of Bcl-2 in CD45dimCD34+CD38-CD123+CD33+population. (FIG. 4B). In AML 4295468, both basal and G-CSF- orSCF-stimulated p-ERK was efficiently down-regulated by cobimetinib;however, G-CSF-evoked p-STAT3/5 and SCF-induced p-AKT were only slightlyreduced. (FIG. 4C). Notably we observed increased phosphorylation ofSTAT5 pathway upon treatment with cobimetinib, suggesting that activeMAPK signals inhibit phosphorylation of the JAK-STAT pathway, aspreviously reported (Krasilnikov et al. Oncogene, 2003 and Lee at al.Cancer Cell, 2014). In AML 4366894, p-ERK was also reduced, however,G-CSF-induced p-STAT3/5 were not significantly changed. To test theefficacy of both compounds in vivo, we injected NSG mice withgenetically engineered OCI-AML3/Luc/GFP cells. Bioluminescent imaging(BLI) demonstrated significantly reduced leukemia burden in treatedgroups compared to controls, more prominently in the cobimetinib singleagent and venetoclax plus cobimetinib co-treated mice. (FIGS. 5A and5B). To further explore the anti-leukemia efficacy of both compounds, weinjected NSGS mice with genetically engineered MOLM3/Luc/GFP cells.Bioluminescent imaging demonstrated significantly reduced leukemiaburden in treated groups compared to controls, more prominently in thevenetoclax group and in venetoclax plus cobimetinib co-treated mice.(FIG. 5C). Human CD45 engraftment and cell counts in both bone marrowand spleen demonstrated a trend towards decreased tumor burden whenvenetoclax was combined with cobimetinib in vivo. (FIGS. 5D and 5E).

In summary, the data demonstrate that combinatorial blockade of MAPK andBcl-2 pathways is synergistic in the majority of AML cell lines testedand can overcome intrinsic resistance to venetoclax. Further,cobimetinib/venetoclax combination inhibited proliferation, inducedapoptosis and reduced clonogenicity in a subset of primary AML samples,but not in normal hematopoietic precursors. In addition, differentiallyoverexpressed proteins were identified in cell lines sensitive orresistant to either single agents or to cobimetinib/venetoclaxcombination. MSD assay revealed that venetoclax but not cobimetinibdisrupted the Bcl-2:BIM complex. CyTOF mass cytometry enablesmeasurements of intracellular signaling pathways and Bcl-2 familymembers in antigen-defined AML stem/progenitor cell populations.Finally, the combination of venetoclax and cobimetinib reduces AML tumorburden and extends survival in OCI-AML3 AML model and MOLM13 AML modelin vivo.

When introducing elements of the present invention or the preferredembodiments(s) thereof, the articles “a”. “an”, “the” and “said” areintended to mean that there are one or more of the elements. The terms“comprising”, “including” and “having” are intended to be inclusive andmean that there may be additional elements other than the listedelements.

In view of the above, it will be seen that the several objects of theinvention are achieved and other advantageous results attained.

As various changes could be made in the above compositions and processeswithout departing from the scope of the invention, it is intended thatall matter contained in the above description and shown in theaccompanying drawings shall be interpreted as illustrative and not in alimiting sense.

1.-16. (canceled)
 17. A pharmaceutical product comprising (i) a firstcomposition comprising[3,4-difluoro-2-(2-fluoro-4-iodoanilino)phenyl]{3-hydroxy-3-[(2S)-piperidin-2-yl]azetidin-1-yl}methanone(cobimetinib) or a pharmaceutically acceptable salt thereof, and (ii) asecond composition comprising4-(4-{[2-(4-chlorophenyl)-4,4-dimethylcyclohex-1-en-1-yl]methyl}piperazin-1-yl)-N-({3-nitro-4-[(tetrahydro-2H-pyran-4-ylmethyl)amino]phenyl}sulfonyl)-2-(1H-pyrrolo[2,3-b]pyridin-5-yloxy)benzamide(ABT-199) or a pharmaceutically acceptable salt thereof.
 18. Thepharmaceutical product of claim 17 wherein the first composition furthercomprises a pharmaceutically acceptable excipient.
 19. Thepharmaceutical product of claim 17 wherein the second compositionfurther comprises a pharmaceutically acceptable excipient.
 20. Thepharmaceutical product of claim 17 wherein the first composition and thesecond composition are the same.